PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1) This is the complaint regarding deficiency in service on the part of Opposite Parties as they partly allowed and partly disallowed the mediclaim of the Complainant.
2) The facts of the complaint as stated by the Complainant are that, the Complainant has obtained a mediclaim policy from the Opposite Party No.1. The Policy Number is 11200/48/04/87723. The Complainant was admitted in Breach Candy Hospital for CAD, PTCA.
3) The Complainant has further stated that after discharge, he lodged his claim with Opposite Party No.3. Hospital issued the bill and he filed a claim of Rs.3,64,080/- with Opposite Party No.3 on 08/07/2005. The Opposite Party No.3 allowed the claim of only Rs.1,05,000/- on 20/10/05 but disallowed the claim of Rs.2,59,080/- after more than 3 months. Therefore, it is alleged by the Complainant that Opposite Parties have failed to provide proper service to the Complainant by rejecting the claim of Rs.2,59,080/- and caused mental tension to the Complainant. Therefore, the Complainant has prayed that the Opposite Party be ordered to pay a total amount of Rs.4,59,080/- to the Complainant with interest @ 12% p.a. from 08/07/05 till realization of entire amount. (It is not understood) as to how the Complainant has came to this amount of Rs.4,59,080/-.
4) It is seen form the complaint that he had obtained a mediclaim policy and during the validity of the mediclaim policy he was hospitalized for C.A.D. and PTCA and he incurred an expenses of Rs.3,64,080/-. He submitted the mediclaim of this amount but the Opposite Party disallowed the claim of Rs.2,59,080/-. Therefore, the Complainant has filed this complaint for reimbursement of these expenses and for the compensation for mental stress, etc.
5) The Complainant has attached the xerox copies of the following documents in support of his complaint, such as - Mediclaim policies, correspondence with Opposite Party, Bills, Discharge card and Pathological & X-ray reports.
6) The complaint was admitted and notices were issued to Opposite Parties. Opposite Party No.1 appeared before this Forum and has filed its written statement wherein it denied almost all the allegations of the Complainant and specifically stated that the claim was settled as full and final settlement for the sum of Rs.1,05,000/- on 20/10/05. This amount was accepted by the Complainant. Hence, the Complainant is not maintainable and there is no cause of action. Secondly, the Complainant was having HT and the same was pre-existing and thus, excluded from the policy.
7) It is contended by the Opposite Party that, the claim is settled for Rs.1,05,000/- rest is not admissible as per the terms and conditions. The Complainant is not entitled to any relief as prayed for in the complaint.
8) Thereafter, the Complainant filed his affidavit in evidence and written argument wherein he reiterated the facts and points raised in his complaint. The Opposite Party No.1 also filed its affidavit of evidence and written argument wherein it reiterated the facts and points raised in its written statement.
9) We heard the Ld.Advocate for the Complainant and perused the papers submitted by the Opposite Party and our findings are that, the Complainant is a mediclaim policy holder of the Opposite Party No.1 and he has obtained this policy since 27/02/1999 till 26/02/2007. The sum assured was Rs.3 Lacs and during the validity, he was hospitalized in Breach Candy Hospital from 20/02/05 to 21/02/05 for C.A.D. i.e. Coronary Artery Disease, PTCA to LAD as per discharge card of Breach Candy Hospital. After the discharge, the Complainant submitted his claim form to the Opposite Party No.3 which has been received by Opposite Party No.3 on 08/07/05. The claim was for Rs.3,64,080/- but, the Opposite Party No.3 settled the claim vide its voucher dtd.20/10/05 for Rs.1,05,000/- only stating the reason as follows “H.T. which in exclusion of the policy, is attribution to Heart Ailment hence, SI restricted to Rs.1,05,000/-.” The above said reason given for non reimbursing the rest of the claim Rs.2,59,080/- is certainly absurd and meaningless. As per the averment of the Complainant the original policy incepted in the year 1992 and this averment is not denied by the Opposite Parties. The Complainant has also produced the policies from 1999. Even in this policy, the exclusion clause contains only “Any treatment related to prostrate glands.” Therefore, from 1999, the heart ailments were not excluded from the policy and the expenses on these ailments were reimbursable. In policy for period 2005-2006, H.T. is included in the exclusion clause but H.T. is not CAD or PTCA. H.T. cannot be construed as CAD, for which the Complainant was hospitalized. The Opposite Parties have given reason for rejecting the claim as the H.T. as a pre-existing disease it cannot be accepted. This is certainly a deficiency in service on the part of Opposite Parties as they have partly rejected the legitimate claim of the Complainant.
10) In this case the total sum assured is Rs.3 Lacs and bonus accrued is Rs.5,000/-. Therefore, the Complainant is entitle to total claim of Rs.3,05,000/-. The Opposite Parties have settled the claim for Rs.1,05,000/- which has been received by the Complainant but the voucher was not signed as a protest. Thus, now the Complainant is entitled to only Rs.2 Lacs towards the reimbursement of his medical expenses.
11) The Complainant has prayed for Rs.2,59,080/-. In view of the above observation this amount is not tenable. He is entitled to Rs.2 Lacs only as the sum assured is Rs.3 Lacs and bonus accrued is Rs.5,000/- only. The Complainant is also entitled for mental agony caused to him due to the deficiency in service on the part of Opposite Parties at this age of 75 years plus. Therefore, taking into consideration the above facts and circumstances of the case, we pas the order as follows -
O R D E R
i.Complaint No.171/2007 is partly allowed.
ii. All the Opposite Parties are jointly and/or severally liable for the deficiency in service by not settling the
legitimate mediclaim of the Complainant as per the terms and conditions and schedule of the insurance
policy.
iii. All Opposite Parties are directed to reimburse Rs.2,00,000/- (Rs. Two Lacs Only) to the Complainant jointly
and/or severally alongwith interest @ 12 % p.a. from 09/07/2005 till its payment.
iv. All Opposite Parties are directed to pay a compensation of Rs.10,000/- (Rs. Ten Thousand Only) to the
Complainant jointly and/or severally for mental agony caused to the Complainant because of their deficiency
in service as explained above.
v. All Opposite Parties are also directed to pay an amount of Rs.5,000/- (Rs.Five Thousand Only) to the
Complainant jointly and/or severally towards the cost of this complaint.
vi. All Opposite Parties are directed to comply with the above said order within 30 days from the receipt of this
order.
vii. Certified copies of this order be furnished to the parties.
