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

          Complainant by filing this complaint has submitted that he purchased one mediclaim policy being No.100500/48/11/850000/6699 for the period 11-03-2011 to 10-03-2012 for herself and her husband Partha Sarathi Mitra and during validity of the said policy Partha Sarathi Mitra was admitted to Narayana Hridayalaya Hospital on 11-12-2011 and he was discharged on 16-12-2011 after successful installation of stent and implant.

          In the said treatment complainant had to incur a sale of Rs.2,37,727/- only as medicine, Hospital charges and cost of stent and implant which is evident from the final bill issued by the concerned Hospital.

          On the day of discharge from the Hospital that aforesaid bill had been paid by the complainant through Debit Card amounting to Rs.30,000/-, Rs.17,727/-, Rs.40,000/-, Rs.50,000/- and Rs.1 lakh i.e. total Rs.2,37,727/-. 

          After discharge from the Hospital Partha Sarathi Mitra, the beneficiary of the mediclaim policy, the proposer of mediclaim policy i.e. the complainant filed claim form duly filled in being no.NI-6-86654 before the TPA Genins India TPA Ltd. for amounting to Rs.2,40,885/-.  After submission of necessary bills, the TPA asked for some documents by a letter dated 15-02-2012 and, thereafter, complainant submitted it and considering the bills and claim the TPA granted only Rs.31,605/- although as mediclaim policy, the complainant is entitled to get maximum sum of Rs.1,25,000/- as sum insured subject to restriction and conditions as made out in the said insurance contract. 

But as per Clause 1.0 Sub Section C of the Insurance Contract the Insurance Company undertakes to pay 50% of cost of stent and implant per illness and also entitled to get Hospital care charges maximum limit 25% of the sum insured, here the complainant has paid a sum of Rs.15,280/- only which is below the maximum limit of Rs.31,250/-.  So, complainant is entitled to get maximum limit of 50% of sum insured i.e. amounting Rs.62,500/- and the complainant under the aforesaid head have incurred a sum of Rs.1,28,642-14 paisa but the TPA with consent of the Insurance Company did not pay single pence in the head on lame excuse, although there is no whisper in the insurance contract, if the amount  incurred in any head become greater than the amount entitled to get, then the entire amount will be repudiated same as the head of Diagnostic & Material in which complainant have incurred amounting to Rs.32,615/- which is below the limit of maximum limit.  Though insurance company agreed to provide necessary service related to medical treatment but when the time had come they did not perform the obligation which they had undertaken to be performed in pursuance of mediclaim contract.  So, it is no doubt deficiency in service as well as unfair trade practice and moreover TPA arbitrarily deducted the expenses for medicine bills were presented before the organization with claim form and also deducted the amount for pathological test without any cogent ground although the expenses afore mentioned was undertaken to pay by the insurance company.

In the above circumstances, complainant has prayed for refund of Rs.78,790/- as net amount after deducting paid amount of Rs.31,605/- only along with 50% cost of the stent and implement, medical and other relief.

On the other hand by filing written version OP2 has submitted that the entire claim of the complainant is not at all maintainable in favour of the fact that OP2 is the only third party administrator, his duty is only to settle the claim by the complainant and after acceptance the claim would be handed over to Insurance Company as the Insurance company is direct authority to made payment and it is also submitted that OP 2 has no deficiency of service in respect of settling the claim and as OP2 already informed the insurance Company about the decision in respect of the claim lodged by the complainant and if the Insurance Company deals in settlement of the same OP2 has nothing to say and accordingly they have prayed for dismissal of the case against the OP2. 

National Insurance Company practically by filing written statement has submitted that they have already paid an amount of Rs.45,525/- to the insured after considering the maximum limit as per the contract and in the body of the written version that has been clearly depicted.

OP1 have also stated that the complainant related to coronary artery diseases in the background of diabetes and hypertension in the policy period 17-03-2011 and 16-03-2012 and the clinical documents reflect presence of diabetes and hypertension for 4-5 years and 10 years respectively and as both hypertension and diabetes are high risk factors for developing coronary artery disease, the present claim get restricted to the sum insured of Rs.75,000/- and the earned CB on the said amount in the policy year of claim the enhance sum insured of Rs.35,000/- in 2007-2008 and Rs.15,000/- in 2008-2009 gets excluded from coverage for any pre-existing condition get covered by the sum insured after four continuous policy years.  Further it is submitted that on review further payment of Rs.36,337/- had already been mentioned and communicated to the representative of the insured and the said amount Rs.36,337/- will be sent through ECS on receipt of Bank A/c. details but that complainant company submits that after total evaluation of the claim OP already paid Rs.45,525/- and at present they are willing to pay balance 36,337/- to the insured as per policy condition and through ECS on receipt of bank details and accordingly the complaint should be dismissed.

Decision with Reasons

On proper condition of the entire materials on record and also considering the policy it is found that sum insured by the policy holder is Rs.1,25,000/- so under any circumstances complainant cannot claim any amount excess to Rs.1,25,000/-.  Truth is that complainant in his complaint admitted that his sum insured is Rs.1,25,000/- but he submitted a claim in respect of Rs.2,37,727/- but truth is that OP had already paid Rs.45,525/- and after considering other aspects they are willing to pay further amount of Rs.36,337/- and if the said two amounts are paid then total payment to complainant is Rs.81,862/- out of sum assured Rs.1,25,000/- and in this regard we have gathered that as per medical insurance policy Clause 1.0 in the event of any claim becoming admissible under this scheme, the company will pay to the insured person the amount of such expenses as would fall under different heads and accordingly as per that clause complainant is entitled to room rent, boarding, Nursing expenses to the extent of 1% of the sum insured per day subject to maximum of Rs.5,000/- and in case of surgeon, anesthetist, medical practitioner, consultants specials fees, maximum limit per illness 25% of sum insured and for x-ray, dialysis, chemotherapy, radiotherapy, cost of pacemaker, artificial limits and cost of stent and implant, maximum limit per illness 50% of sum insured and after considering the written version of the OP1 and also their assessment of claim it is clear that the insurance company against each head assess the sum and decided finally to release Rs.81,862/- and out of that Rs.45,525/- had already been released and complainant had received it and in any case complainant is not entitled to 50% of the total medical cost and for stent and implant he is entitled to 50% and in respect of surgeon fees and other 25% in respect of room, boarding, nursing expenses etc. 1% and adding this three items we have gathered that the OP has rightly assessed the claim of the complainant and properly assessed further payment of Rs.36,337/- and no doubt complainant was asked to submit his savings bank account but that has not been submitted by the complainant but after proper assessment of the entire assessment of claim as made by the OP1 including the mediclaim insurance policy we are convinced to hold that the OP properly decided the said claim and in fact initially OP paid Rs.45,525/- and that has been received by the complainant which is admitted and complainant is entitled to balance Rs.37,337/- from the OP and OP already assessed and willing to pay but complainant did not send his bank account for which it has not been transmitted.

          Considering all the above facts we are convinced to hold that there was no deficiency in service or negligence on the part of the OP and no doubt OP must have to release Rs.36,337/- along with Rs.4,000/- to the complainant as compensation considering the present situation of the complainant.  No doubt complainant has failed to prove any negligence or deficiency on the part of the OP when the claim of the complainant has already been settled and partly paid by the OP.  

In the result, the complaint succeeds.

Hence,

Ordered

That the case be and the same is allowed on contest with a cost of Rs.500/- (Rupees Five thousand only) against the OPs.

          OP1 Insurance Company is hereby directed to reimburse Rs.36,337/- (Rupees Thirty six thousand three hundred thirty seven only) as final payment of the claim amount and also a sum of Rs.4,000/-(Rupees Four thousand only) considering the harassment of the complainant because OPs ought to have sent it to the complainant by cheque but that has not been done and also the age of the complainant the compensation is awarded.

          Accordingly, OP is hereby directed to pay Rs.36,337/- as final payment + Rs.4,000/- as compensation + Rs.500/- as litigation cost i.e. Rs.40,837/-(Rupees Forty thousand Eight hundred and thirty seven  only) to the complainant within one month from the date of this order and in the mean time within 7 days complainant shall have to send his bank account IFS Code No. in details so that OP may comply the order within the stipulated period by transmitting the same in account of the complainant.  if complainant fails to comply the order in that case automatically the OP shall not transmit the said amount but OP shall be very dynamic in this regard so that within one month the decree may be satisfied by the OP otherwise OP shall be penalized for which penal action may be taken by this Forum.