JUDGEMENT

          Complainant by filing this complaint has submitted that complainant took a Mediclaim Policy (Baristha Mediclaim) with the National Insurance Co. Ltd. bearing Policy No. 100600/48/12/85000009215 and it was valid from 23.12.2012 as a renewed policy.

          On 05.12..2012 complainant was admitted with Medica Superspeciality Hospital as he was under high fever associated with urine overflow and he was discharged from the said hospital on 25.12.2012 and entire Bill of Rs. 3,70,049/- was paid for said treatment charges and it is pertinent to note that the said complainant previously admitted to the Hospital on 26.11.2012 for treatment and was discharged on 27.11.2012, the complainant in that case paid Rs. 87,948/- for cost of treatment and as per his bill to TPA and TPA released Rs.43,000/- only as reimbursement amount of the total claim.  So, out of the entire amount of Rs. 1,00,000/- + Bonus Rs.10,250/-, TPA paid only Rs.43,000/- thereby the balance amount of Rs. 67,250/- is still lying with the Insurance Co./TPA.  But after discharge from the said Hospital on 25.12.2012, complainant handed over all the documents to his agent, Sri Sagar Bhatacharya who deposited on 11.04.2013 along with claim form dully filled up and was duly deposited with the TPA along with necessary papers.

          Subsequently as per advise of the TPA dated 29.04.2013 complainant submitted further documents  in original as required by the TPA vide Claim Form dated 11.04.2013 and TPA received it duly on 09.05.2013.  Subsequently TPA asked the complainant to file duplicate of the original bills issued by the said Hospital when complainant learnt that TPA lodged the original mediclaim bills.  But even then complainant followed that instruction and supplied the authenticated duplicate bills and complainant vide E-mail dated 26.06.2013 invited the attention of the TPA to the documents submitted by him dated 09.05.2013 towards reimbursement.  Thereafter complainant highlighted the matter before the Consumer Affairs Department.  But ultimately op released a sum of Rs.25,049/- and after receipt of the same, complainant was astonished because there is no explanation for settlement of delay and there is no cause shown for deduction of balance amount of Rs. 42,201/- which was not paid to the complainant.  So complainant being dissatisfied with the over act of the ops’ prayed for releasing a sum of Rs.42,201/- out of total claim amount and as per policy terms and conditions of sum insured when op refused to do that.  In the circumstances complainant has prayed for redressal.

          On the other hand op the Insurance Company by filing written statement submitted that no doubt the complainant is the holder of Baristha Mediclaim Policy with sum insured of Rs.1,00,000/- valid from 23.12.2011 to 22.12.2012 and fact remains Ranjit Prasanna Sengupta was hospitalized on 26.11.2012 previously and subsequently the present case is submitted for the bill of his present treatment and on previous occasion out of sum insured of Rs.1,00,000/- and a sum of Rs.42,895/- was paid and in respect of present claim only Rs.25,049/- was paid and Heritage Health TPA reported the matter to the complainant in details showing the details of deduction and admissible amount was settled  and it was paid to the complainant and complainant has received it.  So, the present complaint is not maintainable in the eye of law.

                                                        Decision with reasons

          On proper study of the complaint and written version and hearing the argument it is found that for non-submission of original money receipts, medicines charges and other could not be settled.  Truth is that Hospital Authority did not supply the receipt in respect of rent charges of the room, OT charges or laboratory charges separately.  But fact remains that the Hospital Authority submitted detailed bills signed by them showing it is received and that is total of Rs.3 lakhs and above and each head in detail is described.  But moot question is why the room rent was not released.  When fact remains that in respect of the present claim op has admitted that complainant was admitted for treatment in the present Superspeciality Hospital for the period from 05.12.2012 to 25.12.2012 and as because he was treated during that period in the hospital, op themselves released hospitalization charges of Rs.25,049/- as admissible bill. Then it is clear that he was hospitalized and then what prevented the op to release Rs.1,000/- per day as room charge for 20 days that is Rs.20,000/-, may be there is no separate receipt issued by the Hospital Authority.  But total bill in details has been submitted with seal, signature showing payment of the same.  So, in this regard we find that complainant is entitled to Rs.20,000/- for room rent no doubt.

          Further complainant is also entitled to Rs.12,000/- for medical treatment and other cost what has been raised by the Hospital Authority and accordingly they are entitled to get Rs.32,000/- from the op and op did not release in view of the fact that in respect of that no separate receipt in those cases are submitted by the Hospital Authority.  But total bill was issued by the Hospital Authority and Hospital Authority received the toal amount but complainant was not entitled to get more than Rs.1,00,000/- of the sum insured and as because complainant already received Rs.67,944/-, so complainant at present is entitled to Rs.20,000/- for 20 days room charge and Rs.12,000/- for medicines and other cost and accordingly complainant is entitled to get another Rs.32,000/- from the op/Insurance Co. Ltd. and op Insurance Co. is bound to pay that though in this case complainant in the complaint has tried to convince that he is entitled to Rs.42,201/- but that is not correct in view of the fact it is settled principal of law that in a year total reimbursement shall not cross the sum insured and after giving this amount of Rs.32,000/- in favour of the complainant sum insured of Rs.1,00,000/- is already touched.  So, no further sum can be granted in favour of the complainant and complainant is not entitled to get the same as per terms and conditions of the policy.  Accordingly the complaint succeeds.  But fact remains deficiency and negligence on the part of the op is not proved because op rightly refused certain claim but fact remains such a technical fault must not be taken into account by the Insurance Co. in all cases.  When in this case particularly for hospitalization some charges are paid.  Then hospital charge, room charge must be granted but that is not released.  It is no doubt a technical fault on the part of the hospital authority and complainant failed to prove the deficiency and for which we are not granting any sort of other relief because we are releasing the amount of Rs.32,000/-.

          In the result, the complaint succeeds.

          Hence, it is

                                                                ORDERED

          That the complaint be and the same is allowed on contest against the op but without any cost.

          Op Insurance Co. is hereby directed to pay a sum of Rs.32,000/- to the complainant within one month from the date of this order and without any fail.  Hearing the claim is finally settled and if op/Insurance Co. fails to comply the order in that case op/Insurance Co. shall have to pay punitive damages @ Rs.100/- per day till full satisfaction of the decree and if it is collected then it shall be deposited to this Forum.

          Ops/Insurance Co. is hereby directed to comply the order very strictly failing which penal action shall be started u/s 27 of C.P. Act 1986 and for which further penalty and fine may be imposed.