Complainant Gouri Chatterjee by filing this complaint has submitted that complainant and her husband are joint mediclaim policy holders of the op Insurance Company since 2002 and they are regularly paying their premium in respect of their policy in time and have renewed the said mediclaim policy every year in time.
Complainant and her husband accordingly on 12.07.2013 took mediclaim policy of the said op being Policy No. 51010034130100002911 for the period of 12.07.2013 to 11.07.2014 for the sum insured of Rs. 1,00,000/- each and thereafter they renewed the said policy from the period of 12.07.2014 to 11.07.2015 and in total sum assured is Rs. 2,00,000/- from the period 12.07.2014 to 11.07.2015 and the total sum insured have been increased by the complainant from Rs. 1,00,000/- to Rs. 2,00,000/-.
Suddenly on 14.07.2014 complainant fell ill and visited the concerned doctor for her treatment and further visited on 16.07.2014 and she was advised by the concerned doctor for fissure and piles on 22.07.2014 and accordingly as per advice of the doctor, she was admitted in the Woodlands Hospital on 21.07.2014 for having her surgery fissure and piles and on 22.07.2014 the said surgery was done by the concerned doctor of the Woodlands Hospital and during treatment some clinical tests had been done at the said hospital and complainant was discharged from the said Woodlands Hospital on payment of treatment cost of Rs. 92,862/-.
In fact on 24.07.2014 the intimation for hospitalization have been informed to the op Insurance Company and on 07.08.2014 the claim form along with all other relevant documents have been submitted by the complainant before the op Insurance Company for reimbursement of her claim amount in respect of her Policy No. 51010034142500002101 which was duly received on 07.08.2014 by the op. Thereafter suddenly on 12.09.2014 op no.3 Medicare TPA Service Pvt. Ltd. remitted an amount of Rs. 25,348/- out of total claim of Rs. 92,862/- and transferred it to the account of the complainant through NEFT without any intimation and clarification to the complainant. After knowing that fact, complainant lodged a complaint to the ops’ authority for arbitrary deduction of huge amount out of the total claim when policy is for Rs. 2,00,000/- per member as per policy. But they did not pay any heed to that and in fact op deliberately deducted such amount without any foundation and without considering the policy terms and conditions and illegally and whimsically deducted such amount and for which the complainant has prayed for relief and for directing the ops to pay balance amount of the total mediclaim and cost etc.
On the other hand op nos. 1 & 2 by filing written statement admitted that complainant purchased that policy and they are bona fide purchasers of policy since long period and admittedly the insured amount was enhanced and new policy was issued being Policy No. 51010034142500002010 for the period of 12.07.2014 to 11.07.2014 for sum insured of Rs. 2,00,000/- as per new Mediclaim Policy was issued.
No doubt complainant filed this complaint regarding claim of the complainant and wherefrom it reveals that complainant claimed of Rs. 94,720/- for her mediclaim treatment. But op paid only Rs. 25,548/- after considering the Clause 3.1 of the terms and conditions of the Mediclaim Insurance Policy. There was no negligence and deficiency on the part of the op and reimbursement of Rs. 25,348/- was made by the op forthwith after full and final settlement and on receipt of the money, no complaint was lodged and it was accepted unconditionally and in fact there was no short-comings or inadequacy of the claim and their performance on the part of the op. So, complainant is not entitled to get any relief and prayed for dismissal of this case.
Decision with reasons
On proper study of the complaint and written version and also on proper assessment of the documents filed by both the parties and also relying upon the arguments as advanced by the Ld. Lawyers of both the parties it is found that it is admitted position that complainant and her husband are Mediclaim Policy holders since 12.07.2002 and that is specifically mentioned in the Policy No. 51010034130100002918 for the period from 12.07.2013 to 11.07.2014 and same is also noted in the New Policy No. 51010034142500002101 for the period from 12.07.2014 to 11.07.2015.
Admitted position is that for the year 12.07.2013 to 11.07.2014 sum insured per Insured was Rs. 1,00,000/-. But it was enhanced for the next year from 12.07.2014 to 11.07.2015 and sum insured was Rs. 2,00,000/- each. But considering the two policies, it is clear that complainant and her husband are continuously continuing the mediclaim policy since 12.07.2002 under the op. So, under any circumstances even if it is accepted that the Clause 3.1 is applied by the op in that case invariably complainant is entitled to room rent, doctor’s fees, investigation charge, operation theatre charge etc. at the rate 1 percent p.a. over the sum insured of Rs. 2,00,000/- not over previous of Rs. 1,00,000/- sum insured.
But in the present case op assessed at the rate 1 percent over Rs. 1,00,000/- which is completely illegal in view of the fact that there is no question of any deduction over one lakh in respect of that policy because it is continuously continued since 2002 for which after considering the content note of the Medicare TPA Services Ltd. dated 10.11.2014, it is clear that op TPA without considering the condition of the policy and without properly assessing the entire matter and terms and conditions and the status of the complainant and her husband as continuous Mediclaim Policy holder since 2002 only settled the matter by giving effect of 1 percent of over Rs. 1,00,000/- which is completely illegal. But op ought to have settled the matter by giving the effect of at the rate 1 percent over the sum insured of Rs. 2,00,000/- and that has not been done which is no doubt uncalled for and arbitrary in nature.
Admitted fact is that assessment of the claim as made by the op was on the basis of sum insured of Rs. 1,00,000/- at the rate 1 percent p.a. assessing of doctor’s fees, investigation charges, operation theatre charge etc. But it would be at the rate 1 percent over the sum insured of Rs. 2,00,000/- and it is fact that Rs. 25,348/- was transmitted to the account of the complainant out of the total claim of Rs. 94,720/-. But considering the sum insured of Rs. 2,00,000/- and assessment of room rent, doctor’s fees etc. at the rate1 percent and other charges, complainant is entitled to actually another amount of Rs. 25,348/- because op assessed the same at the rate 1 percent p.a. over Rs. 1,00,000/- but it would be 1 percent over Rs. 2,00,000/- and after proper assessment, we have gathered that complainant is entitled to Rs. 50,696/- in total. But ops have released only Rs. 25,348/-.
So, complainant is entitled to further sum of Rs. 25,348/- from the op because total settled amount ought to have been Rs. 50,696/-. Truth is that op assessed the said mediclaim of the complainant on the basis of sum insured of Rs. 1,00,000/- which is completely uncalled for, arbitrary and illegal.
In the light of the above findings we are inclined to hold that no doubt op processed the said mediclaim of the complainant very arbitrarily as per Clause 3.1. No doubt complainant is entitled to 1 percent for room rent, doctor’s fees, investigation charges, operation theatre charge at the rate 1 percent p.a. over Rs. 2,00,000/- and other charges accordingly. So, complainant is entitled to get total sum of Rs. 50,696/-. But ops assessed Rs. 25,348/- and that has been paid no doubt and in fact same was paid back behind the knowledge of the complainant without taking any final voucher from the complainant and such sort of practice on the part of the op is no doubt uncalled for and in future invariably op must not have to follow such policy. But before transmitting any amount after settlement must be reported to the Mediclaim Policy holder and his consent must be taken in this regard, otherwise if consent is not given by Mediclaim Policy holder, in that case, settled the amount shall not be remitted to the account of the policy holder but not otherwise.
In the light of the above observation, the complaint succeeds. No doubt ops are bound to pay a further sum of Rs. 25,348/- when we have assessed the final settled amount of Mediclaim Policy to the extent of Rs. 50,696/- and further op shall have to pay litigation cost including some compensation for adopting such un-reasonable method of assessing mediclaim of the complainant.
Hence, it is
ORDERED
That the complaint be and the same is allowed on contest against the op nos. 1 & 2 with a cost of Rs. 5,000/- and same is allowed exparte against op no.3 the Medicare TPA Services Ltd. but without any cost.
Op nos. 1 & 2 are hereby directed to pay a further sum of Rs. 25,348/- to the complainant within one month from the date of this order and also shall have to pay a sum of Rs. 5,000/- for arbitrarily deducting that amount out of actual total settled amount of Rs. 50,696/-.
Accordingly op nos. 1 & 2 are hereby directed to pay a total sum of Rs. 35,348/- within one month from the date of this order to the complainant failing which for disobeyance and non-compliance of the Forum’s order, op nos. 1 & 2 shall have to pay penal damages at the rate Rs. 100/- per day 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 the order, in that case, the penal action u/s 27 of C.P. Act 1986 shall be started for which they may be penalized further penalty and fine.
