Order No.                 .

This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint submitted that he along with his wife, son and mother are covered by a mediclaim policy being No.150100/48/11/8500012567 dated 16-03-2012 and said policy commenced on and from 05-03-2012 to 04-03-2013 and during that validity period of the said mediclaim insurance policy complainant admitted his mother, Mrs. Saleha Begum in Fortis Hospital in 18-04-2012 for treatment of her respiratory problem but unfortunately after undergoing medical treatment for nearly a month, she expired on 18-05-2012 but Fortis Hospital after allowing a discount of Rs.1 lakh raised a bill of Rs.3,47,102/- on account of hospitalization costs, medicines costs, doctors fee/expenses of his mother which was duly paid by the complainant from his own money. 

          After the death of her mother Saleha Begum the complainant filed his claim on 15-06-2012 to the OP2 for reimbursement of the medical expenses amounting to Rs.3,47,102/- along with all original copies of relevant documents all medical bills and documents as required by the OP and subsequently complainant received a cheque of Rs.1,77,550/- along with claim payment statement dated 23-10-2012 from the OP2 as against the claim amount of Rs.3,47,102/- and on receipt of the same he became surprised and the reason for short payment was not at all satisfactory for which complainant again submitted a letter with a request to reconsider the balance amount because it was within the ambit of the terms and condition of the policy but the OPs even after receipt of the letter dated 14-12-2012 ignored to reply and also did not pay the balance amount and in the above circumstances the complainant considering their negligent and deficient manner of service filed this case for releasing a sum of Rs.1,29,375/- as the balance amount, as cost of treatment of her mother and for compensation etc.

          Against that National Insurance Company by filing a written statement submitted that the present complaint is completely barred by limitation and at the same time it is not maintainable in view of the fact there is no deficiency and negligence on the part of the OP and the OP disposed of the matter as per terms and condition and complainant encashed it and no other objection was raised even after receipt of the said cheque so the complaint is not maintainable at the same it is specifically submitted that the entire claim, was decided as per certain terms and condition of the policy and it is limited to the provision and condition of the policy and applying that method as enumerated in the terms and condition of the policy the bill was decided and balance bill was not paid because it was not admissible in the eye of law and when deficiency and negligence on the part of the OP then the complainant is not entitled any relief and then the claim should be dismissed.

Decision with Reasons

On careful consideration of the complainant and written statement including argument as advanced by the lawyer of the OP and also considering the claim payment statement it is clear that complainant lodged a claim of Rs.3,47,102/- and out of that deduction was made to the extent of Rs.1,69,552/- and settled amount of Rs.1,77,550/- had already been paid to Saukat Ali vide cheque No.88093 dated 22-11-20123 and that had already encahsed by the complainant and truth is that his mother was admitted to Fortis Hospital on 18-04-2012 and she was discharged after her expiry on 18-05-2012 and intimation of her admission was reported on 19-04-2012.  After thorough scrutiny of the calculation sheet including deduction as made by the OPs it is clear that OP rightly deducted Rs.30,600/- out of the total ICCU charges and actually the OP paid Rs.70,200/- that is quite correct and regarding deduction of Rs.39,650/- in respect of charges for Section A room, nursing etc. was also justified in view of the fact.  OP granted room charges of Rs.18,200/- and further granted Rs.70,200/- for ICU charges.  So, it is apparent that from room charges and ICU charges OP granted Rs.88,400/-.  So, no other room charges can be granted in favour of the complainant.  But complainant claimed Rs.1,19,000/- as room charges etc. but that has already been properly decided by the OP so, deduction to that effect was no doubt correct.  Truth is that OP did not deduct any other item of the claim of the complainant as per medical bill except the deduction in case of room and ICU charges.  But after proper calculation it is found that OP deducted Rs.99,302/- for room and ICU charges and other nursing charges etc.  But in this regard we have gathered that deduction as per policy condition would be Rs.49,000/- so balance Rs.51,000/- should be paid by the OP to the complainant, and, in fact, complainant is entitled to get back it from the OP but truth is that Fortis Hospital out of total payment bill of Rs.4,47,102/- gave a discount of Rs.1 lakh and accordingly complainant paid Rs.3,47,102/- but Fortis Hospital did not mention against 10 heads of bills in respect of which head how much amount was deducted and that is no doubt a fault of Fortis Hospital if that amount would be deducted as per head in that case the complainant’s position would be otherwise but even then considering all the above facts and considering the deduction we find that deduction if it would be from room tariff then invariably complainant must not get present amount given against the present room and ICU at the same time as per clause it is found that at this stage after thorough check up of the calculation sheet including the policy condition at best complainant is entitled to Rs.51,000/- because the deduction was made by the TPA considering new condition of the policy but that was not the policy condition when it was purchased and for which it was refused as per terms and condition.  So, complainant is entitled to get back further amount of Rs.51,000/- only and fact remains it was not the fault on the part of the OP.  OP deducted it as per new terms and condition but without the knowledge of the complainant but truth is that there is a revised terms and condition as per IRDA Rules but we are relying upon old terms and condition and we are directing the OP insurance company to release the sum of Rs.51,000/- and we are convinced that there was no fault, laches on the part of the OP because OP finally disposed of the claim and admissible part of the claim was received by the complainant and encashed so, apparently negligence and deficiency on the part of the OP are not proved.  At the same time the calculation as made by the OP as per new terms and conditions was quite correct but even then considering the death of her mother and old terms and condition OP to pay a cheque of Rs.51,000/- to the complainant on the basis of the old terms and condition of the policy.  In the result, the complaint succeeds.

Hence,

Ordered

That the case be and the same is allowed on contest against the OPs but without any cost.

          OP Insurance Company is hereby directed to issue a cheque of Rs.51,000/- to the complainant treating it as a final settlement of the claim in respect of which complainant has received another amount of Rs.1,77,550/- and OP Insurance Company is directed to satisfy the decree within one month failing which for non-compliance of the Forum’s order OP Insurance Company shall have to pay punitive damages of Rs.100/- per day till full satisfaction of the decree and punitive damages if collected it shall be deposited to this Forum.

          OP Insurance Company is hereby directed to deposit the amount and for non-compliance of the order penal action shall be started against him or their administration for which they shall be liable.