PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1)This is complaint regarding the deficiency in service on the part of Opposite Party as it partly allowed and partly disallowed the mediclaim of the complainant.
2)The facts of this case as mentioned by the complainant are that, the complainant has obtained a mediclaim insurance policy bearing number-11180/34/09/11/000/1948 valid from 15/11/2008 to 14/11/2009- having sum assured Rs.3,00,000/-. The complainant was hospitalized in Bombay Hospital from 07/03/2009 to 14/03/2009 for her back pain. The total expenditure for the treatment, including pre-hospitalization and post hospitalization was Rs.1,35,893/- Out of this expenditure a sum of Rs.69,393/- was paid by the Opposite Party to the hospital being cashless settlement. The hospital bill was of Rs.83,917/- Balance of Rs.14,524/- was paid by the complainant.
3)Thereafter on 27.04.2009 the complainant filed a claim form, claiming Rs.66,500/- for the above hospitalization alongwith all original medical bills, prescriptions, discharge card and all other relevant papers. Then, the complainant received a claim settlement letter dtd.02/06/2009 from the Opposite Party alongwith a cheque of Rs.17,643/- towards full & final settlement of the claim. Thus the Opposite Party arbitrarily settled the claim for Rs.17,643/- The complainant stated that she has not enchased that cheque of Rs.17,643/- till date as a protest against the arbitral settlement by the Opposite Party.
4)The complainant then sent a letter dtd.06.06.2009 disputing the arbitrary final settlement by the Opposite Party for Rs.17,643/- The complainant also sent a letter dtd.11/08/2009 giving exact break up as per the bills and also showing the amount unpaid by the Opposite Party. The Opposite Party required the original report of a laboratory bill for Rs.6,000/-. The complainant therefore sent the same as required by the Opposite Party. Then the complainant received a cheque of Rs.5,400/- from the (cheque dtd.03/04/2010) whereas the bill for laboratory investigation was to Rs.6,000/-. Thus, the Opposite Party arbitrarily deducted Rs.600/- from this amount also. The Complainant has enchased the above cheque of Rs.5,400/-.
5)The Complainant further requested the Opposite Party to settle the genuine claim vide her letter dtd.17/12/09, 15/02/2010 and 25/03/2010, but the Opposite Party did not reply the said letters. Finally the Complainant through advocate addressed a letter dtd.05/05/2010 to the Opposite Party calling upon it to settle the balance claim of Rs.61,100/-. Upon this, the Opposite Party vide its letter dtd.17/05/2010, informed the Complainant that, the Opposite Party is considering the claim of the Complainant but thereafter there is no response from the Opposite Party. This has caused mental agony to the Complainant and therefore, the Complainant has prayed that the Opposite Party be directed to reimburse the balance amount of the claim i.e. Rs.61,100/- with interest @ 24 % p.a., Rs.50,000/- towards mental agony.
6)The Complainant has attached the xerox copies of the following documents alongwith the complaint -
Copy of Power of Attorney, Insurance Policy, Claim Form dtd.27/04/09, Letter dtd.02/06/09 & letter dtd.06/06/09, Letter dtd.11/08/09, Legal Notice dtd.05/05/2010, Letter dtd.17/05/2010 of Opposite Party to the Complainant.
7) The Complaint was admitted and notice was served on the Opposite Party. It appeared before this Forum through its Ld.(Learned) Advocate and filed the written statement wherein it is denied by the Opposite Party that the total expenditure including post hospitalization was Rs.1,35,893/-. Opposite Party has stated that the Complainant has not adduced any evidence to show that the expenditure was to the tune of Rs.1,35,893/-.
8) The Opposite Party has denied that the Complainant submitted a claim form dtd.27/04/09 for the balance of Rs.66,500/-. Further in the same para, the Opposite Party submits that the claim form shows the exorbitant amount claimed by the Complainant for which she was not entitled as per terms and conditions. In this para, the Opposite Party has completely denied at first instance that the Complainant has submitted claim form dd.27/04/09. This is a certainly wrong statement made by the Opposite Party in its averment and in the next sentence, it submits that, the Complainant has submitted the claim form but amounts are shown exorbitant. This is absolutely contradicting averments of the Opposite Party. The Opposite Party has also not explained or clarified that, how these amounts are exorbitant.
9) Further the Opposite Party has stated that, the claim was processed by the Opposite Party and as per the terms & conditions the amount of Rs.17,643/- was given to the Complainant.
10) The Opposite Party has further justified its sanction of the amount of Rs.5,400/- against the laboratory expenses of Rs.6,000/- submitted by the Complainant and it justified that this amount is rightly sanctioned as per the terms & conditions. But at the same time, the Opposite Party does not give the actual term and condition which specifies the category of the Complainant and reduces the amount from Rs.6,000/- to Rs.5,400/-. Finally the Opposite Party has stated that the complaint be dismissed with compensatory cost.
11) Thereafter, the Attorney of the Complainant has filed his affidavit of evidence and written argument wherein the facts mentioned in the complaint are reiterated.
12) We heard the Ld.Advocates for both the parties and perused papers submitted by both the parties. Taking into consideration the papers submitted by both the parties our findings are as follows.
13) The Complainant has obtained a Mediclaim Insurance Policy from the Opposite Party. The policy was valid from 15/11/08 to 14/11/09. The sum assured was Rs.3 Lacs having no exclusion of any disease. During the validity of this policy, the Complainant was hospitalized in Bombay Hospital form 07/03/09 to 14/03/09 for back pain. The mediclaim policy being a cashless policy, the Opposite Party has sanctioned a cashless claim of Rs.69,393/-.
14) The foremost objection of the Opposite Party is for the total expenses of Rs.1,35,893/-. The Opposite Party wants a proof for such expenses.
In this connection we perused papers and we find that, the claim form which was received by the Opposite Party on 27/04/09, contains the details of these expenses but, the Complainant has not submitted the actual bills. It is the contention of the Complainant that all the bills were submitted to the Opposite Party alongwith the claim form dtd.27/04/09. It is clearly mentioned in handwriting as “Enclosed original receipts of Bombay Hospital Receipt No.81193423, all original receipt of expenses incurred No.1 to 22 items above. Therefore, it is clear from the contents of this claim form that the Complainant had submitted the bills & documents showing the expenses incurred by her on her hospitalization. The total amount claimed was clearly mentioned as “Rs.1,35,893/-. And after deducting the sanctioned amount of Rs.69,393/-, the Complainant has rightly claimed an amount of Rs.66,500/- for the rest of the expenses not sanctioned by the Opposite Party.
15) The Opposite Party has gone to the extent of denying the fact that the Complainant has not submitted the claim form. But the stamp of the Opposite Party clearly shows that this claim form of the Complainant claiming Rs.66,500/- was received by the Opposite Party on 27/04/09. Thus, the Opposite Party is making submissions to mislead the Forum and at the same time making false averment. In the same para, in the next sentence, the Opposite Party avers that the claim in the claim form is exorbitant as per the terms & conditions. But, the Opposite Party miserably failed to show, how the claim is exorbitant and which are the terms and conditions which show that the claim of the Complainant is exorbitant.
16) In the next paragraphs, the Opposite Party admits that it processed the claim of the Complainant. Thus, it is clear from its averment only that the Complainant had submitted the claim and it processed the said claim and settled it for Rs.17,643/-. The Opposite Party here again failed to clarify as to how it settled the claim only for Rs.17,643/- as against the Complainant’s claim of Rs.66,500/-.
17) After settlement of the claim for Rs.17,643/- by the Opposite Party, the Complainant has taken objection for this settlement and clarified in her subsequent letters dtd.06/06/09, 11/08/09 and 05/05/2010 that she has incurred expenses of Rs.1,35,893/-, but the Opposite Party has sanctioned only Rs.69,393 + 17,643/- + 5,400/-. Out of this sanctioned amount she has not encashed the cheque of Rs.17,643/- as a protest against Opposite Party. She has also clarified about, what are the actual expenses and what amount the Opposite Party has allowed and what amount remained to be given to the Complainant in letter dtd.05/05/2010. But the Opposite Party by its letter dtd.17/05/2010 communicated to the Complainant in printed form that “they are taking up your grievance with the concerned policy issuing office No.111800 and revert to you on hearing from them”. Since then there has been no response from the Opposite Party. This is really a pathetic situation and amounts to deficiency in service.
18) From the papers and bills submitted by the Complainant it is the fact that she has incurred expenses of Rs.1,35,893/- and till date she received only Rs.74,793/-. She has not received remaining amount of Rs.61,100/-. Cheque of Rs.17,643/- was allowed by the Opposite Party but it was not encashed by the Complainant. The Opposite Party has not given any tenable reason for rejecting the rest of the amount payable to the Complainant. Thus, the Complainant is entitled for reimbursement of Rs.61,100/- for the expenses she incurred on her hospitalization. The Opposite Party is deficient in service by rejecting the legitimate mediclaim of the Complainant. This deficiency in service of the Opposite Party has caused mental agony to the Complainant. Therefore, we pass the order as follows –
O R D E R
i.Complaint No.208/2010 is partly allowed.
ii The Opposite Party is directed to pay of Rs.61,100/- (Rs. Sixty One Thousand One Hundred Only) to the
Complainant wit interest @ 10 % p.a. from 27/04/2009 till its payment.
iii.Opposite Party is directed to pay Rs.10,000/-(Rs. Ten Thousand Only) to the Complainant for mental agony
caused to the Complainant because of the deficiency in service on the part of Opposite Party.
iv.Opposite Party is directed to pay Rs.5,000/-(Rs. Five Thousand Only) to the Complainant towards the cost of
this complaint.
v.Opposite Party is directed to comply with the above order within 30 days from the receipt of this order.
vi.Certified copies of this order be furnished to the parties.
