Ex-P A R T E O R D E R
PER SHRI. S. G. CHABUKSWAR – HON’BLE MEMBER
1) This is a complaint for the reliefs of reimbursement of medical expenses Rs.3,27,311/- with interest @ 21 % p.a., compensation Rs.1,50,000/- for mental agony and Rs.20,000/- cost of the complaint.
2) The case of the Complainant in short is as under –
The Opposite Party has issued to the Complainant two Mediclaim Policies bearing No.111400/34/09/11/00002477 for Rs.4,00,000/- and it’s expiry period was on 11/05/2010 and second mediclaim policy bearing no.111400/34/09/11/00004215 for Rs.1,00,000/- and it’s expiry period was on 11/06/2010. The bonus of 35% was also on both the policies.
3) The further case of the Complainant is that, on 27/10/2009, he was admitted in the hospital for treatment of Bypass Surgery and he was discharged on 03/11/2009. The Complainant had informed to the Opposite Party the fact of his hospitalization and bypass surgery in advance. The Complainant incurred the total medical expenses Rs.7,66,125.77 paise however, the total policy amount of both the policies of the Complainant was Rs.6,75,000/- therefore, he submitted with the Opposite Party the claim form for Rs.5,14,125.77 paise. The Complainant has also submitted the copies of discharge card, hospital and medical bills and other documents alongwith the claim form on 22/12/2009.
4) The further case of the Complainant is that, Opposite Party paid Rs.2,00,000/- as cashless amount directly to the hospital and thereafter, paid Rs.1,47,689/-. The Complainant had enquired with the TPA about the claim amount but the TPA made false promise and informed that the claim is under process and it will take time. The Opposite Party has paid only Rs.3,47,889/- out of total policy amount Rs.6,75,000/-. The balance claim amount of the Complainant towards the Opposite Party is Rs.3,27,311/-. Lastly on 04/11/2011 the Complainant issued notice to the Opposite Party and demanded the said amount. The Opposite Party served with the notice but Opposite Party neither paid the balance claim amount nor replied the notice. Hence, this complaint for the reliefs mentioned in above para no.1.
5) The Opposite Party duly served with the notice but remained absent, hence, complaint proceeded ex-parte against the Opposite Party.
6) The Complainant has submitted his affidavit of evidence and written notes of argument. We have gone through the documents produced by the Complainant. We heard oral argument of Shri. Rajesh Dedhia, Ld.Advocate for the Complainant.
7) The Complainant has deposed on oath in his affidavit of evidence the entire facts narrated by him in the complaint. The Complainant has produced alongwith written argument at page no.5 & 6 the copies of two insurance policies. The policy submitted at page no.6 shows that the Complainant has purchased from the Opposite Party Mediclaim Policy bearing No.111400/34/09/11/00002477 for the period from 12/05/2009 to 11/05/2010 for the insured sum of Rs.4,00,000/-. The policy submitted at page no.5 shows that the Complainant has purchased Mediclaim Policy bearing No. 110000/34/10/11/00003519 for the period 12/06/2010 to 11/06/2011 for insured sum of Rs.1,00,000/-. The previous policy number has been shown therein as 111400/34/09/11/00004215 of the year 2009. The Complainant is claiming the amount of medical expenses covered by the insurance policy bearing No. 111400/34/09/11/00004215. The Complainant has specifically pleaded in the complaint that the expiry date of the said policy was 11/06/2010. The Complainant has deposed the aforesaid fact in his affidavit of evidence. From the above evidence and copy of policy filed at page no.5 alongwith written argument of the Complainant, it is clear that the mediclaim policy bearing no.111400/34/09/11/00004215 was valid for the period 12/06/2009 to 11/06/2010 for the sum of Rs.1,00,000/-. The bonus amount of 35% have also been shown in both the policies submitted alongwith written argument by the Complainant at page no.5 & 6. The evidence available on record shows that the Complainant had taken two policies one of Rs.1,00,000/- and the another for Rs.4,00,000/- and the bonus amount of both policy was Rs.35,000/- and Rs.1,40,000/- total amount Rs.6,75,000/-.
8) The Complainant has submitted alongwith written argument from page no.13 to 16 the copies of cheques and receipts of fees paid to the doctors. As per the above receipts and cheques the Complainant has paid total Rs.4,55,000/- to Dr. Sudhanasan Bhattacharya towards fees of professional service. The Complainant has also submitted the copies of bills issued by Bombay Hospital and Medical Centre from page no.17 to 25. The Complainant has also produced a certificate issued by the above hospital on 28/10/2009. As per the said certificate the Complainant was admitted in the above hospital for bypass surgery on 27/10/2009 and he was discharged on 03/11/2009. The total hospitalization expenses were Rs.3,02.778 and was covered by cashless for Rs.2,52,000/-. The Complainant paid the balance amount. The Complainant has also submitted alongwith written argument the statement of expenses from page no.10 to 12 and claim form at page no.9. The Complainant has shown the grant total of medical expenses Rs.7,66,129.77 paise. As per the evidence and documents produced by the Complainant, it appears the amount Rs.3,27,311 of medical expenses has not been paid to the Complainant by the Opposite Party. The above evidence and documents produced by the Complainant remained unchallenged. There is nothing on record to disbelieve the above evidence of the Complainant. The Opposite Party has rendered the deficiency in service to the Complainant by not paying the balance claim amount. In view of the above evidence, we find that the Complainant is entitled for the reimbursement of medical expenses Rs.3,27,311/- from the Opposite Party with interest @ 6% from the date of filing of compliant till the realization of the amount, compensation Rs.5,000/- for mental torture caused to the Complainant and cost of the complaint Rs.3,000/-.
In the result complaint deserves to be partly allowed with cost. Hence, we proceeds to pass following order –
O R D E R
- Complaint No.326/2011 is partly allowed with cost as under -
- Opposite Party is directed to pay to the Complainant reimbursement of medical expenses Rs.3,27,311/- (Rs. Three Lacs Twenty Seven Thousand Three Hundred Eleven Only) with interest @ 6% p.a. from the date of filing of the complaint till realization of amount.
- Opposite Party is directed to pay to the Complainant compensation Rs.5,000/- (Rs. Five Thousand Only) for mental torture caused to him.
- Opposite Party is directed to pay to the Complainant Rs.3,000/- (Rs. Three Thousand Only) towards the cost of the complaint.
- Opposite Party do pay the amount mentioned in para no. ii to iv to the Complainant within one month from the date of this order.
vi. Certified copies of this order be furnished to the parties.
