Complainant by filing this complaint has submitted that she is the holder of a Mediclaim Policy bearing NO. GH MAR 0900610 and 712500334083800000034 having A/C No. 45500388615088007 for self which was issued under Cashless Mediclaim Scheme for sum assured of Rs. 1 lac which was increased to Rs.1.25 lac due to no claim bonus addition by the Insurance Company with servicing by the TPA M/s TTK Healthcare Services Private Limited.

          During subsistence of the said valid policy complainant was admitted to AMRI Hospital, Dhakuria for treatment of Cancer was detected and matter was intimated to TPA, Kolkata about her admission on 28.05.2009 and the Hospital Authority sent a total bill of Rs.1.61 lacs and that was sent to TPA up to 10.06.2009 that is up to the date of release.  But the insurer settled the claim by sending Rs. 53,700/- to the Hospital in spite of reminder they did not give any response on the balance Rs.71,300/-.  So, the complainant’s family was compelled to pay the said balance bill for her release.  It is further alleged that only to harass the complainant op asked the complainant to submit original receipts of payment issued by the AMRI Hospital, though the original final bill was already sent to them on 04.11.2009 which contained details of the payments made to the Hospital by her family on different dates and TPA informed that original receipts of Rs.5,000/-, Rs.20,000/- and Rs.33,625/- were submitted along with the bill and the receipt for Rs.49,500/- were misplaced at that time and final reminders were sent by the complainant on 12.05.2010 and 21.06.2010.  But even then the said amount was not released.  So, ultimately finding no other alternative complainant submitted the complaint to Insurance Company Ombudsman’s office at Kolkata who issued an award on 06.08.2012 advising the Insurance Company to settle whatever the company proposed to settle during discussion at Ombudsman’s office without looking into the perspective and without giving proper hearing.

          But the company did not settle the matter, though Ombusdman directed the op to pay Rs.45,536/- but that was also not paid by the op for which for deficient and negligent manner of service this complaint is filed.

          On the other hand, op by filing this written statement submitted that fact remains as per table of benefit in Clause 1.1, the maximum of 30% of sum insured is payable towards profession fees of doctors and 40% of the sum insured is payable towards O.T. charges, medicines and diagnostics etc and further that 30% of the sum insured is reimbursable on account of room rent, ICU, nursing charges and so the total amount was assessed of Rs.53,800/-.  But as because the original bill in respect of Rs.49,500/- was not submitted that was not disbursed or decided.  Further it is submitted that when the Ombudsman issued order as per order of the Ombudsman op expressed their desire to pay Rs.45,536/- in addition to previously paid Rs.53,700/-.  But complainant was asked to file an Indemnity Bond that was sent to the complainant but complainant did not response. 

          Fact remains the Ombudsman passed award dated 23.07.2012.  Fact remains the op then sent reminder on 24.09.2012 for performing the part of obligation of the complainant to comply with the said award passed by the Ld. Insurance Ombudsman but that too went unheard.  So, in the above situation op was unable to comply the order of the Ombudsman though they were ready to hand over Rs.45,536/-.

          It is specifically mentioned in the written version that as and when op received the notice of this Forum in connection with this case, op was ready to pay the said amount without any prejudice subject to her indemnification of affidavit missing voucher as settled by the Ld. Ombudsman and fact remains Cashless facilities was given to the complainant and as per Clause 1/1 that was allowed and paid and when op is and was ready to pay that amount of Rs.45,536/- to complainant but complainant did not receive it.  So, there were no latches on the part of the op and for which the entire complaint should be dismissed.

                                             Decision with reasons

          Fact remains in this case on receipt of the complaint by the op, op submitted one cheque being No.10675 dated 23.05.2013 in favour of the complainant in respect of sum as of Rs.45,536/- and that was deposited to this Forum on 27.06.2013 but during continuation of the present proceeding complainant was asked to receive it but complainant refused for which the cheque was returned by this Forum ultimately on 06.11.2013 for biased attitude of the complainant and the case was heard finally after closure of the case for judgement.

          No doubt we have gone through the entire complaint, and written version including the order of the Ombudsman wherefrom we have gathered that Ombudsman after hearing both the parties prepared a chart and calculated the payment and asked the op to pay Rs.45,536/- and that order was passed on 23.07.2012 and on the basis of the complaint of the complainant and it was specifically ordered by the Ombudsman that complainant shall have to submit indemnity bond at the time of releasing the amount by the op and complainant was also asked to submit it within 15 days and op was also asked to release the same within 15 days.  But after considering the entire dispute anxiously we have gathered that complainant was very much arrogant and did not comply the order of the Ombudsman and did not file any affidavit or Indemnity Bond in support of loss or original receipt and further it is found that cheque was submitted by the op before this Forum on the date of their appearance on receipt of the notices of the complainant but some person’s ill advice might be, complainant did not receive the cheque.  So, we have gathered that matter was expeditiously decided by the Ombudsman and award was given to the complainant but complainant did not avail of it.  Op was always ready and their readiness is proved from the fact that they submitted their cheque on the date of their appearance in this case but complainant did not receive it.  So, we find that the present complainant as consumer appeared before this Forum with un-cleaned hand and there is no question to decide any further matter on the ground the matter was finally decided and considered by the Ombudsman and gave relief to the extent of Rs.45,536/-.  Op sent reminders to the complainant to receive the said amount but that was not received by the complainant. 

          So, considering the entire conduct we have found that such a consumer is not willing to comply the order of the Ombudsman also and for which her entire complaint is proved false, fabricated and uncalled for one and vexatious also.

          In the result, the complaint is dismissed.

          Hence, it is

                                                     ORDERED

          That the complaint be and the same is dismissed on contest but without any cost.

 But we are directing the complainant to go to the op’s office to submit indemnity bond/affidavit at once and receive the cheaue in respect of the amount of Rs.45,536/- and if complainant does not comply that matter in that case op shall have to sit idle.