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

          Complainant by filing this complaint has submitted that he purchased a mediclaim insurance policy by paying valuable consideration i.e. adequate insurance premium and that policy covers medical disbursement against medical ailments suffered during the subsistency of the said insurance policy.

          During the subsistency of the said policy on or about 16-04-2013 the complainant suffered a retinal detachment in his left eye and underwent surgery on 18-06-2013 at BB Eye Foundation, Kolkata and the surgery was performed by Dr. Sourav Sinha, Vitreoretinal Surgeon and for that purpose various test were done on that date and complainant was discharged on 19-04-2013.

          The hospital raised a bill for a total sum of Rs.32,100/- and complainant paid a sum of Rs.10,400/- in cash to the hospital and thereafter, complainant paid Rs.21,700/’-in cash to the Dr. Sourav Sinha, being his professional fees and complainant incurred an expenditure of Rs.3,085/- for undergoing various pathological test and purchase of medicine relating to the eye ailment.  Thus complainant spent a total medical expenses of Rs.32,100/- + Rs.3,085/-  = Rs.35,185/- and in respect of that amount complainant lodged an insurance claim being No.241400366 with the OP Insurance Company and the said Insurance Claim was suo-moto referred by the Insurance Company to the Proforma OP without the knowledge and consent of the complainant.  Thereafter, vide a letter dated 03-09-2013 proforma OP informed that they have unilaterally repudiated a part Rs.12,186/- out of the total claim and released finally a sum of Rs.22,999/- and that was transferred to the Bank Account of the complainant/insured.

          It is specifically mentioned that contract of insurance was a bilateral contract between the complainant and OP1, the Proforma OP is a mere stranger to the contract from whom no service has been hired by the complainant and, as such, the said stranger Proforma OP has no legal authority to repudiate a substantial part of the bona fide mediclaim of the complainant/insured.  In the above circumstances, the complainant vide his letter dated 08-02-2013 informed that he had not accepted the lesser amount that has been transferred unilaterally to his account and on receipt of the aforesaid letter of protest the Proforma OP vide letter dated 10-10-2013 stated that they have chose not to allow a total sum of Rs.12,186/- on varied head. 

          It is specifically mentioned that the final bill was issued by the Hospital Authority for which surgeon charges was of Rs.21,700/- is not in dispute.  Even then a sum of Rs.10,000/- has been deducted arbitrarily and mala fide on a vague and frivolous ground and OP has further not paid a sum of Rs.2,186/- being the cost of medicine and pathological test and fact remains OP has not relied upon the medical certificate issued by the authority and also did not consider the receipt on the basis of which medicine was purchased as per prescription of the doctor.  Though admitted position is that he underwent an eye surgery for rectification of detachment of retina, he had lodged a bona fide mediclaim for a total sum of Rs.35,185/- and even such paltry claim has been drastically reduced on mere technical plea, there is no bona fide ground on the part of the OPs but without any legal ground they have deducted such amount which the complainant is entitled to as per a mediclaim policy and as per medical bill issued by the OP. 

          On the other hand OP New India Assurance Company by filing written statement submitted that amount surgeon fees was paid directly to the doctor which was Rs.21,700/- and as per condition of policy Note 2 under 2.3 (note No.2) “no payment shall be made under 2.3 other than as part of the hospitalization bill”.  However, there was some relaxation and under Note No.3(b) “Fees paid in cash will be reimbursed upto a limit of Rs.10,000/- only, provided the surgeon/Anesthetist provides a numbered bill” and for which the TPA (Heritage Health TPA Pvt. Ltd.) had no alternative but to pay Rs.10,000/- leaving Rs.11,700/- as prayed for surgeon operation charge.

          Rs.100/- towards establishment charge was not paid under Clause 4.4.22.  Clause 4.4. states Permanent Exclusion that any medical expenses incurred for or arising out of 4.4.22 service charges or any other charges levied by hospital, except registration/admission charges.

          It is specifically mentioned that Rs.385.45 towards medicine was not paid in absence of Doctor’s advice which is under preamble condition No.1 similarly Rs.27.45 for medicine was also not paid under identical ground and condition No.1 is all the policies are quite Ok in this regard.

          In fact TPA as per mediclaim policy terms and condition disallowed that amount as it was not possible to grant due to condition of the policy and the decision of the present OP is based on application of mind and relying upon the conditions.  So, such a repudiation is legal and varied and there is no negligence and deficiency on the part of the OP and disallowing the claim of amount of Rs.1,286/- by TPA is no doubt legal and valid and for which the present complaint should be dismissed.

Decision with Reasons

On proper consideration of the entire materials on record and after hearing the Ld. Lawyers of both the parties and also considering the vital documents that is the final bill issued by the BB Eye Foundation dated 23-04-2013 and on proper consideration of the said final bill issued by the BB Eye Foundation dated 23-04-2013 and the final bill issued by the BB Eye Foundation where complainant underwent eye operation it is clear that bed charges was Rs.1,700/- and OT Charges Rs.8,700/- vide bill No.BB/OT/00037 and Surgeon Charges was Rs.21,700/- vide receipt No.1529 dated 19-04-2013.  So, considering that bill it is clear that BB Eye Foundation issued receipt in respect of bed charges, OT charges and Surgeon charges and when surgeon received that amount from the BB Eye Foundation surgeon also received that amount on 19-04-2013 on the basis of the receipt No.1529 and in respect of bed charges BB Eye Foundation issued separate bill along with OT Charges and thereafter, BB Eye Foundation after discharge handed over final bill Rs.32,100/- then question is how the OP refused balance amount in respect of surgeon charges.  Fact remains receipts are there with receipt no. date etc.  Peculiar factor is that the doctor did not operate in his chamber and that doctor was deputed by the BB Eye Foundation and in this regard there is no denial on the part of the OP.

          On behalf of the OP, Ld. Lawyer submitted that the operation charges of Rs.21,700/- only was received by Dr. Sourav Sinha by issuing a separate receipt but that was not issued by BB Eye Foundation for which as per clause the complainant is entitled to get only Rs.10,000/- but not Rs.21,700/- on the ground BB Eye Foundation did not issue any such bill.  Considering the argument of the Ld. Lawyer of OP and also considering the condition of the policy it is found that Heritage Health TPa Pvt. Ltd. did not consider that the operation was done at the BB Eye Foundation.  BB Eye Foundation deputed the doctor and that doctor Sourav Sinha did operation on the left eye of the complainant due to retinal detachment and he was there for one complete day and thereafter, he was discharged from there and about operation there was no denial because part payment has been made.  So, only simple question is whether the doctor received his fees as part of the final bill issued by BB Eye Foundation or not.  In this regard we have gathered that the bill of the BB Eye Foundation was issued on 23-04-2013 wherefrom it is found no separate head bills were granted in favour of the patient.   Surgeon charges was paid by the B B Eye Foundation and invariably after collecting it from the complainant, complainant himself also paid such charges, OT charges paid to the B B Eye Foundation and fact remains in all private Nursing Home and Hospital Doctor charges are paid after collecting it from the client and doctor issues such bill in the name of the patient after discharge on the ground that the surgeon charges or doctor charges are calculated with the private nursing home or hospital in that case the said authority shall come under the purview of the income tax only to avoid their such liability after operation the doctors receives such amount from the hospital etc. but receipt is granted in favour of the patient.  That is the procedure so that doctor may pay tax against their PAN Number when it is not the income of the hospital and or nursing home and this simple practice is followed by all private nursing home and hospital to save themselves from paying additional tax for which doctors fee cannot be restricted by the TPA or Insurance Company by any means.  But for that reason that receipt cannot be treated as separate receipt for any separate operation but it is a part of the entire operational charge.  Anyhow, Heritage Health TPA Pvt. Ltd. has already settled the claim and made payment and by such act their name is already the name of the Heritage list only for their dutiful work to discharge the claim of the insured in many cases.  But they have their no judicious outlook to determine the clause and the document.   Practically in this case in a very causal manner the claim of the complainant for balance Rs.12,186/- is curtailed for no legal and valid ground.  But in casual manner the conditions and terms and conditions are being applied by the Heritage but in this case it is fact that complainant purchased a policy which is admitted by paying a premium of Rs.27,901/- and policy coverage is Rs.5 lakhs.  Such an insured even after payment of mediclaim premium of Rs.27,901/- claimed Rs.32,100/- but out of that claim Rs.12,186/- was deducted.  We feel that it is completely immoral act, truth is that final bill was issued by the BB Eye Foundation that was not considered.  Fact remains complainant has not suppressed anything but even then they have not relied upon the final bill of the BB Eye Foundation which is no doubt uncalled for and without any legal foundation and fact remains OP Insurance Company also did not apply any judicial approach in determining the claim but they no doubt released a part payment that is Rs.22,999/- out of Rs.32,100/- and, in fact, Rs.11,700/- was deducted out of total Surgeon Fees of Rs.21,700/- but considering the entire material and also considering the final bill issued by the BB Eye Foundation dated 23-04-2014 we are confirmed that complainant paid Rs.32,100/- to BB Eye Foundation out of which BB Eye Foundation received Rs.1,700/- for bed charges and for OT charges Rs.8,700/-vide a same bill and surgeon charges Rs.21,700/- vide receipt No.15239 dated 19-04-2013.  So, we find that final bill which was submitted by the BB Eye Foundation is valid and legal and there was no illegality.  So, OPs ought to have relied upon said bill and released Rs.11,700/- which has been deducted from the total surgeon charges of Rs.21,700/- but without applying such judicial mind OP casually accepted the TPA’s decision without applying their good sense and for which we are convinced to hold that complainant no doubt is entitled to get Rs.11,700/- which has not been released by the OP showing some technical ground and such a technical ground cannot be taken into account in view of the fact it is social legislation and at the same time consumer paid practically huge amount as premium that is Rs.27,901/- for one year mediclaim policy and sum insured is Rs.5 lakhs.  Amount as claimed is meager and that has been also not considered which is no doubt a deceitful manner of activities on the part of the OPs and for which we are convinced to hold that complainant is entitled to further Rs.11,700/- when admitted position is that a sum of Rs.22,999/- has already been paid out of total claim of Rs.35,185/-. 

Accordingly, the complaint succeeds.

Hence,

Ordered

That the case be and the same is allowed on contest against the OP1 with a cost of Rs.3,000/- and same is allowed against OP2 without any cost.

          OP1 is hereby directed to pay a sum of Rs.11,700/- in addition to already paid Rs.22,999/- to the complainant without any further delay and invariably within one month from the date of this order along with litigation cost.  But no other relief can be granted when deficiency and negligence on the part of the OP1 is not proved. 

OP1 is hereby directed to comply this order within one month from the date of this order and to satisfy the decretal amount of Rs.14,700/-(Rs.11,700 + Rs.3,000/- as litigation cost) failing which for each days delay penal interest  at the rateRs,200/- per day shall be assed till full satisfaction of the decree and if it is collected it shall be deposited to this Forum’s Account.

Even if it is found that OPs are reluctant to comply this order in that case penal action u/s.27 of C.P. Act, shall be started against them for which they shall be further imposed penalty and fine.