Order-15.
Date-02/03/2016.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant by filing this complaint has submitted that he is the mediclaim policy holder being no.101100/65/14850003241 which was renewed for a further period of one year from 26-06-2014 to 25-06-2015 on payment of renewal premium totalling a sum of Rs.22,106/- and the sum insured for the said mediclaim policy is Rs.5 lakhs and credit of Rs.1,75,000/- as no claim bonus thereby aggregating to Rs.6,75,000/-.
In the month of September, 2014 complainant slipped at his residence causing injury to his left wrist and he was admitted at the Breach Candy Hospital on 12-09-2015 at about 19.31 hrs. for wrist implantation where he was treated by Surgeon Sanjay Agarwala. Prior to admission certain tests were conducted by the hospital authority for which they charged Rs.4,450/- and after admission the hospital billed Rs.1,55,675-04 towards bed charges and others Rs.40,000/- towards fees of Anesthesist and Rs.2 lakh towards charges of Surgeon thereby aggregating to Rs.3,59,675/- and a sum of Rs.75,000/- was deposited on 12-09-2014 another Rs.2 lakh was deposited on 14-09-2014 and the remaining amount was paid by the complainant to the Hospital authority on discharge.
On release the complainant submitted its claim of Rs.3,64,125/- on 30-09-2014 including payment made to the hospital for various testing etc. and the claim papers in original were sent to Genins India TPA Ltd who is the administration agent of the OP in respect of the present claim. The claim of the complainant for Rs.3,64,125/- was assigned claim control no.NI-6-155313 and the said TPA sought few further documents which were also sent to the said TPA on 05-11-2014. Complainant lost or misplaced some of the original advance money receipt of Rs.2 lakh ad three paid receipts worth of Rs.4,450/- by Breach Candy Hospital Authority and admitted the claim anyhow amounting to Rs.1,59,675/- but on frivolous ground balance amount has not been paid for which complainant made several representation and admission and TPA submitted that on the basis of the duplicate money bill further claim cannot be adjudicated and further some deduction has been made specifying some clause and disallowed the balance claim.
The acts of the OP in refusing the balance claim of the complainant is completely baseless and without any foundation and in the above circumstances, complainant prayed for redressal and for directing the OP for releasing the balance amount of the claim.
On the other hand, OP insurance company by filing written statement submitted that the present claim is not tenable in the eye of law. No doubt complainant submitted a claim for Rs.3,64,125/- and on verification of the claim along with papers with the said claim TPA decided the same and complainant submitted duplicate medical bills amounting to Rs.800/-, Rs.250/-, Rs.3400/-, Rs.124,186/- and as a consequence the TPA could not settled the claim and TPA communicated vide letter dated 15-11-2014 and its reminder letter dated 21-11-2014 asking the policy holder to submit original money receipts but complainant did not submit the same despite repeated demands made by the OP for which TPA decided the matter accordingly as per terms and condition and settled the claim of Rs.1,59,675/- calculating in strict conformity with the policy condition and guidelines framed under the policy and disbursed the maximum eligible amount of Rs.1,59,675/- by ‘EFT transfer’ in the bank account of the complainant on 13-05-2015 which was duly received by the complainant/claimant. Thereafter, complainant sent their grievance via e-mail but TPA is unable to accede the receipt because complainant failed to produce original bills. So, there was no negligence and deficiency on the part of the OP and claim was settled as per terms and conditions for which the present complaint is not maintainable and the allegation as made by the complainant is completely baseless and have no foundation, laches is on the part of the complainant.
It is specifically mentioned that Clause 10.1 of the policy specifically says that submission of original money receipts, bills, cash memos are compulsory for the sake of settlement of claim of the policy holder but complainant failed to submit original money receipts and therefore, the TPA settled the claim on the basis of the materials and as per terms and condition of the policy so the allegation of the complainant against the OP is completely failse and fabricated. In the result complaint should be dismissed.
Decision with Reasons
On proper consideration of the complaint and the written version including settlement of claim as made by the TPA it is found that against policy no.101100/48/14/8500003247 for policy period from 26-06-2014 to 25-06-2015 sum insured was Rs.5 lakhs and cumulative bonus is Rs.1,75,000/- and no doubt complainant was admitted in Breach Candy Hospital on 12-09-2014 and discharged from there on 15-09-2014 for diagnosis of left lower end Radius fracture with Intra articular Extension. It is undisputed fact that complainant submitted a claim of Rs.3.64,125/- and out of that OP settled the claim by paying 1,59,675/-. Truth is that TPA informed the complainant why the deduction was made in details and that was received by the complainant.
Fact remains deduction of Rs.500/-, Rs.250/-, Rs.3400/- were not considered as original money receipts were not submitted and further some other amount was deducted as same are inadmissible that was also noted such as registration charges for Rs.280/-, sweet lime for Rs.32/- and Rs.71,250/- against Dr’s charge was deducted because as per clause the complainant is entitled to 25 percent of the total sum assured so, Rs.3750/- was deducted against bed charges beyond maximum limit for per day as per policy. So, considering the above facts it is clear that as per Clause 10.1 complainant is duty bound to submit original bills and on the basis of duplicate bill no claim shall be settled. So, considering that fact it is clear that fault is on the part of the complainant and there is no negligence and deficiency on the part of the OPs when that is the fact then it is clear that all the allegation of the complainant against the OP is found baseless but laches is found on the part of the complainant for which we are convinced to hold that there is no negligence, deficiency or any mala fide intention on the part of the OP in settling the claim and truth is that claim was settled on the basis of the valid documents and a sum of Rs.1,59,675/- was duly transmitted to the complainant’s account which is admitted.
In the above facts and circumstances, we are convinced to hold that the claim of the complainant against the OPs is not based on valid papers so the present complaint is not tenable against the OP as deficiency and negligence against the OPs is not at all proved. Whatever, it may be we are directing the Breach Candy Hospital Authority to send their details bill in respect of the patient Anurag Poddar Bed No.701, Admission No.1408533, Admission date 12-09-2014 of Breach Candy Hospital Trust and in this regard Breach Candy Hospital Trust shall also specify in details that is surgical cost and other cost separately and send it to M/s. Genins India TPA Ltd., 15, Ganesh Chandra Avenue, Kolkata – 700 013 and on receipt of the same from the Breach Candy Hospital Authority TPA shall again decide the balance claim as per terms and condition of the policy. Accordingly, this complaint succeeds in part without any cost or compensation.
Hence,
Ordered
That the case be and the same is allowed on contest against the OP Insurance Company but without any cost and also allowed ex parte against other OPs without any cost.
Breach Candy Hospital Trust Authority is hereby directed to send details in patient final bill showing specific cost of particular item in the said bill in respect of patient Anurag Poddar being admission No.1408533, Bed No.701 admission date 12-09-2014 and discharged date 15-09-2014 to M/s. Genins India TPA Ltd. 15, Ganesh Chandra Avenue, Kolkata – 700 013 at once and on receipt of the same by M/s. Genins India TPA Ltd., M/s. Genins India TPA Ltd. and National Insurance Company shall re-decide the balance of the claim of the complainant as per terms and condition of the policy and, thereafter, inform the complainant the fate, accordingly. But no other relief is granted in view of the fact negligence, deficiency or omission on the part of the OPs are not at all proved.
