ORDER                              

Mohd. Anwar Alam, President

1. The complainant filed this complaint on 14-1-2010 and alleged that his father Sh. Pardeep Kumar got mediclaim policy no. 360804/48/08/8500000806 from OP  for his family for a sum of Rs. 4 Lakhs and due premium was paid.  Late Sh. Pardeep Kumar fell ill in November 2008 and hospitalized in Sh. Balaji Action Medical Institute on 7.11.2008 and treated there. Huge expenses of Rs 4,96,130/- were incurred for his treatment. Hence, complainant approached  the OP and OP paid Rs. 10000/- which is a very meager amount against the terms and conditions of the policy of insurance.   On 2.5.2009  Sh Pardeep Kumar died and legal notice dated 28.08.2009 was served on the OP but no response from the OP.  Hence, cost of treatment of Rs. 4,96,130/- along with compensation and litigation charges are prayed by the complainant.

2.  OP admitted the medicalim policy for a sum of Rs. 4 Lakhs which was valid from 24.7.2008 to 23.7.2009.  OP further admitted that complainant has made the first pre-authorization request on 7.11.2008 and on his request an amount of Rs. 12,000/- was sanctioned against it for which the hospital had put up a claim of Rs. 10,780/- which was reimbursed to the hospital subsequently. The second request was received on 21.11.2008  and record of treatment taken in last six days were demanded.  Complainant’s father was suffering from Rheumatoid arthritis and when details in respect of the same were demanded no record of the treatment was given  hence cashless facility was denied and patient was asked to file the claim. But no claim was filed by the complainant and  OP has not repudiated the  same  but the complainant has preferred to file the complaint without any basis. It was further clarified that  the legal notice of the complainant dated 28.8.2009 was replied on 11.9.2009 to the complainant. Hence, the complaint filed by the complainant was premature and deserved to be dismissed with cost. 

3. Complainant filed rejoinder and in support of complaint affidavit of CW1 Sh. Pulkit Rohilla (son of the complainant)   along with document    Ex-CW1/A .   In support of reply OP filed affidavit of Sh. S. Rai (A.O.) and affidavit of Dr. A.K. Batra, (Medical Director) TPA.    Both the parties filed their written arguments.

4.  We have heard the arguments and considered the evidence led by the parties and their   written and  oral arguments.  In this case points to be considered are as under:-

(a) Whether complainant is a consumer?

(b) Whether there is any deficiency in service on the part of the OP ?

( c) Relief?

5. As OP admitted that the mediclaim policy issued in favour of complainant’s father and its validity from 24.7.2008 to 23.7.2009 for sum insured of Rs 4 Lakhs, therefore, complainants are admittedly consumer.

6. From the perusal of the documents submitted by both the parties and affidavits submitted by both the parties it is evident that complainants did not file claim covered under the mediclaim policy.  But the complaint filed by the complainants may be considered as “claim” and even after filing this complaint OP did not consider the allegations made in the complaint which is undesirable from the OP. Admittedly, OP has sanctioned pre-authorisation for an amount of Rs 12,000/- against which hospital’s claim for Rs. 10,780/- was reimbursed to the complainant. It clearly reflects that hospitalization of the complainant’s father was in the knowledge of the OP. Affidavit of Pulkit Rohila in support of the complaint shows that actual amount incurred was Rs 496130/- but he has submitted the medical bills dated 10.11.2008 for Rs. 13,094/-, 3.1.2009 for Rs 95,106/-, 25.1.2009 for  Rs 167056/-, 6.2.2009 for Rs. 72350/- and  2.5.2009 for Rs. 63,824/- totaling to  Rs 4,11,430/-.  Therefore, it is proved that complainant has spend more than Rs  4 Lakhs for the medical treatment of insured person . This amount was not denied by  the OP in his evidence. 
7. Looking to the above facts and circumstances we are of the opinion that refusal to pay the cost of treatment to the complainant in conformity with the insurance policy of the OP for assured sum of Rs. 4 Lakhs is deficiency on the part of OP. As insurance cover given to the complainant was restricted to a sum of Rs. 4 Lakhs , therefore, during the validity of the insurance policy complainant is entitled to recover the assured sum of Rs. 4 Lakhs only minus preauthorization claim of Rs. 10,380/- which equals to 3,89,220/- We , therefore, direct OP as under:-

1. To pay a sum of Rs. 3,89,220/- to the complainant covered under the mediclaim policy.
2. To pay a sum of Rs 20,000/- to the complainant as compensation.
3. To pay a sum of Rs 10,000/- to the complainant as cost of  long litigation between the parties.

8. The above payment will be made by the OP to the complainant within 30 days from the date of order failing which OP shall pay interest @ 10 % p.a. on the above total amount from the date of order till the date of payment. File be consigned to record room.

Announced on this ……………..