This complaint coming up before us for hearing on 27-05-14                                in the presence of Sri Y.Prasanna Kumar, advocate for complainants;                         Sri G. Erukala Reddy, advocate for 1^st opposite party; 2^nd opposite party opposite party set exparte, upon perusing the material on record, and having stood over till this day for consideration this Forum made the following:-

O R D E R

Per Sri A. Hazarath Rao,  President:-      The complainant filed this complaint under section 12 of the Consumer Protection Act seeking reimbursement of Rs.51,635/- together with interest @12% p.a. from            17-08-12 and for costs.

2.   In brief the averments of the complaint are these:

          The complainants are husband and wife.  The complainant for himself and his wife took mediclaim policy for Rs.1,75,000/- each from the 1^st opposite party.  The 1^st opposite party in turn issued mediclaim policy bearing No.2010/55050748108500000420 and it was valid from 20-08-2011 to 19-08-2012.  The 1^st opposite party engaged services of the 2^nd opposite party for processing claims.  The 1^st complainant as per direction of the 1^st opposite party sent claim along with all bills to the 2^nd opposite party for Rs.1,67,197/-.  But the 2^nd opposite party sent cheque for Rs.1,15,562/- with covering letter.  The 2^nd opposite party rejected seven items and reduced the claim without assigning any reason.  The 1^st complainant received the cheque under protest.  The 1^st complainant issued legal notice dated 08-10-12 demanding the opposite parties to remit the balance amount of Rs.51,635/- with interest.  The opposite parties though received notice kept quite without giving any reply.  This opposite party deducting Rs.51,635/- unreasonably amounted to deficiency in service.  The complaint therefore be allowed.    

3.   The 2^nd opposite party remained exparte.

4.    The contention of the opposite party in brief is thus:-

          The complainants are not consumers within the meaning of Consumer Protection Act.  The 2^nd opposite party processed claim of the complainant on all aspects as per terms and conditions of the insurance policy.  As per policy conditions the complainants cannot claim total expenditure said to have been incurred either for treatment or medical or clinical tests, physiotherapy, luxury tax, medical records, diet, administration, service clinical and registration charges. As the opposite parties followed procedure in settlement of claim the complainants are not entitled to the sum of Rs.51,635/-.  The opposite parties did not commit any deficiency of service.  The complaint therefore be dismissed. 

5.  Exs.A-1 to A-5 on behalf of the complainant, Exs.B-1& B-2 on behalf of 2^nd opposite party were marked. 

6.   Now the points that arose for consideration in this complaint are:

          1.  Whether the complainants are consumers within the meaning of

              Consumer Protection Act?

          2.  Whether the opposite parties were justified in deducting

              Rs.51,635/- from out of amount claimed, and if so it amount to

              deficiency in services?

1. To what relief?

7.  Admitted facts in this case are these:

1.  The opposite parties issued mediclaim policy in favour of the complainants and it covered Rs.1,75,000/- each (Ex.B-1).

2.   The 1^st complainant submitted claim along with bills to the 2^nd opposite party for process.

3.    The complaints submitted claim for Rs.1,67,197/- (Ex.A-1).

4.    The 2^nd opposite party issued cheque for Rs.1,51,562/- (Ex.A-3).

5.    The complainants issued notice to the opposite parties through D.T.D.C. courier service (Exs.A-4 & A-5).

 8.   POINT No.1:-   The 1^st opposite party issued subject mediclaim policy after receiving premium.  The opposite parties settled claim of complainants for Rs.1,15,562/- as against Rs.1,67,197/-.  Under these circumstances the contention of the opposite parties that the complainants are not consumers within the meaning of Consumer Protection Act is devoid of merit.  We therefore answer this point against the opposite parties.

9.   POINT No.2:-   The learned counsel for the 1^st opposite party contended that it gave reasons in Ex.A-3 for disallowing claim to the extent of Rs.51,653/- and relied on the terms and conditions of the policy.  Ex.A-2 revealed that the patient Mrs. Lakshmi Kumari.M. (2^nd complainant) took treatment as in patient in KIMS, Secunderabad from 01-11-12 to 12-05-12.  Ex.A-2 further revealed that the complainants paid Rs.1,50,993/- to KIMS.  As per Ex.A-1 claim form the complainants also claimed Rs.4,070/- towards pre hospitalization charges, Rs.2,500/- towards physiotherapy, Rs.6,000/- towards dental expenses, Rs.3,634/- towards post hospitalization charges amounting to Rs.16,024/-.

10.    The learned counsel for the opposite party contended that the opposite party disallowed Rs.51,635/- giving reasons in Ex.A-3 (=Ex.B-2) dated 27-08-12. The opposite parties gave reasons for disallowing certain amount claimed. Therefore the contention of the complainants about opposite parties deducted Rs.51,635/- without giving reasons is unjustifiable.

11.    Ex.B-1 is the copy of insurance policy along with terms and conditions.  Clause 1 of terms of mediclaim insurance policy is extracted below for better appreciation.

       “1.0  In the event of any claim/s becoming admissible under this scheme, the Company will pay to the insured person the amount of such expenses as would fall under different heads mentioned below and as are reasonably and necessarily incurred thereof by or on behalf of such insured person but not exceeding the sum insured in aggregate mentioned in the schedule hereto. 

1. Room, Boarding, Nursing expenses as provided by the Hospital/nursing home room rent limit : 1% of sum insured per day subject to maximum of Rs.5,000/-.  If admitted in IC Unit -2% of sum insured per day subject to maximum of Rs.10,000/-.  Overall limit under this head : 25% of sum insured per illness. 
2. Surgeon, Anesthetist Medical practitioner, Consultants specials fees.  Maximum limit per illness-25% of sum insured. 
3. Anesthesia, blood, oxygen, OT charges, surgical appliances, medicines, drugs, diagnostic material & X-ray, dialysis, chemotherapy, radiotherapy, cost of pacemaker, artificial limbs and cost of stent and implant.  Maximum limit per illness – 50% of sum insured. 

Note:  (a).  Hospitalization expenses of person donating an organ during the course of organ transplant will also be payable subject to the sub limits under “c” above applicable to the insured person. 

(b).  Ambulance charges up to 1% of sum insured subject to a maximum limit of Rs.1,000/- in a policy year will be reimbursed provided registered ambulance is used.  This benefit is available only for shifting patient from residence to hospital if admitted to ICU or emergency ward or from the one hospital to another subject to the sub limits under “C” above. 

© Company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured for the person as mentioned in the schedule”. 

12.    The complainants and opposite parties filed calculation memo.  The complainants claimed Rs.48,188/- towards room rent / nursing and I.C.U charges.  Ex.A-2 disclose that KIMS charged certain amount towards hospital and allied charges, luxury tax, in the item mentioned as “ward charges and amount of Rs.30,330/- as “room charges”.  Clause 1(A) provided ceiling limit per day subject to limit of 1% of the sum insured per day, Rs.10,000/- per day in I.C.U unit subject to 2% of the sum insured per day and overall limit being Rs.25% of the sum insured.   Ex.B-2 calculation memo revealed that opposite party approved Rs.1,750/- per day @ 1% of the sum assured for six days, Rs.3,500/- per day for five days in I.C.U. @2% of sum assured.  The opposite party did not mention the above calculation in Ex.B-2.  In all the complainants claimed Rs.48,188/- towards room rent / nursing and ICU.  The overall limit in clause 1(A) of Ex.B-1 is 25% of the sum insured and it comes to Rs.43,750/-  Under these circumstances the complainant is entitled to the maximum amount mentioned under clause 1(A) 25% sum assured.    But the opposite parties disallowing Rs.20,188/-  in our considered opinion is not justifiable.  Under that head the opposite parties can deduct Rs. 4,438/- (Rs.48,188/- - Rs.43,750/-).  But the opposite parties deducting Rs.20,188/- instead of Rs.4,438/- is unjustifiable. 

13.    The opposite parties disallowed claim of Rs.5,952/- being expenses towards E.C.G, ELEC, BAND, UROBAG, Therm Sheet, Mask, Feed and Lushkit, IV set, EURO meter charges.  The contention of the complainants that word used in clause 1(B) Ex.B-2 “ maximum included items disallowed is also having considerable force.  Under those circumstances disallowing the claim of Rs.5,952/- is improper.

14.    The opposite parties disallowed Rs.7,090/- towards laboratory charges for want of records.  The complainant also did not file any such record before this Forum.  Under those circumstances disallowing of Rs.7,090/- by the opposite parties is justifiable.

15.    The opposite parties disallowed Rs.2,500/- as the complainant claimed towards physiotherapy charges. In the terms of mediclaim insurance policy charges for physiotherapy is not included.  Under those circumstances disallowing of claim by the opposite parties for Rs.2,500/- is justifiable.

17.    The opposite parties disallowed Rs.15,905/- claimed by the complainant under the head other charges contending they included luxury tax, medical records, diet, drug administration, service, clinical registration charges.  The learned counsel for the complainant contended that pre -hospitalization for a period of thirty days and post hospitalization for a period of sixty days will be considered as part of claim as per clause 3.2 of terms and conditions of the policy.

18.    3.1 & 3.2 of mediclaim insurance policy (Ex.B-1) is extracted below for better appreciation:

          3.1 Pre Hospitalization :  Relevant Medical Expenses incurred during period up to 30 days prior to hospitalization/domiciliary hospitalization on disease / illness/injury sustained will be considered as part of claim mentioned under item 1.0 above.

          3.2 Post Hospitalization: Relevant Medical Expenses incurred up to 60 days after hospitalization/domiciliary hospitalization on disease/illness/injury sustained will be considered as part claim mentioned under item 1.0 above. 

19.    The complainant submitting bills for Rs.6,000/- (dental) , Rs.4,070/- (pre hospitalization expenses) and Rs.3,634/- (post hospitalization expenses) to the opposite parties is not disputed.  The opposite party for its best reason did not produce the said bills before this Forum.  The complainants paid Rs.1,50,993/- only to KIMS, Secunderabad.   The complaint as well as affidavit of the 1^st complainant is silent where he/2^nd complainant took treatment for dental and whether that pre hospitalization and post hospitalization charges as claimed related to the treatment taken in KIMS or some other hospital.  For want of necessary particulars the complainants are not entitled to Rs.15,095/-  and the opposite parties are therefore justified in disallowing the said claim.

20.    In view of the afore mentioned discussion opposite parties disallowing the claim of Rs.21,702/- is unreasonable and directing them to pay that amount will meet ends of justice.  We therefore answer this point accordingly.

21.    POINT NO.3:- In view of the above findings the complaint is partly allowed as indicated below :

1. The opposite parties are directed to pay Rs.21,702/- (Rupees twenty one thousand seven hundred and two only) together with interest @ 9% p.a. from the date of complaint till payment.
2. The opposite parties are further directed to pay Rs.2,000/- (Rupees Two thousand only) towards costs of the complaint.

The above order shall be complied within a period of six weeks from the date of receipt of this order.

Typed to my dictation by Junior Stenographer, corrected by us and pronounced in the open Forum dated this the 30^th day of May, 2014.

Sd/-XXX                                                                                            Sd/-XXX

MEMBER                                                                        PRESIDENT

APPENDIX OF EVIDENCE

DOCUMENTS MARKED

For Complainant:

For 2^nd opposite party:-

                                                                                          Sd/-XXX

                                                                                      PRESIDENT

NB:   The parties are required to collect the extra sets within a month after receipt of this order either personally or through their advocate as otherwise t