Ms. Nipur Chandna, Member
The complainant is a mediclaim policy holder of OP no. 1. It is alleged by the complainant that she has been availing the medi claim policy since 2001. It is further alleged by the complainant that in the year 2014 she had enhanced the sum insured under the policy upto Rs.5 lakh and had purchased the mediclaim policy vide policy No. 350100/48/13/8500000859 for the period from 31.3.2014 to 30.03.2015 for a sum insured of Rs.5,00,000/-
It is further alleged by the complainant that she was admitted in Max Super speciality Hospital on 10.6.2014 as she had to undergo knee replacement and after operation she was discharged on 17.6.2014. It is alleged by the complainant that at the time of discharge the said hospital had raised a bill of Rs.4,36,018.25 and when she lodged a claim with OP for reimbursement of the same. It has paid only a sum of Rs.2,00,000/- despite the fact that insurance policy covered the claim upto Rs.5,00,000/-. It is further alleged by the complainant that she had made several requests to the OP to pay the entire claim amount. But no need was paid to her request and she was forced to bear the medical expenses of Rs.2,86,018/- from her own pocket.
The complainant alleged that at the time of issuing the policy, the OP had assured her that the company will pay the medical expenses upto 5,00,000/- but the OP had failed to do so which act of OP amounts to deficiency in service and hence this complaint.
Insurance company has contested the complainant and has filed its reply. It has denied any deficiency in service on its part and has prayed for dismissal of the complaint.
Para 3 of the reply for the written statement is relevant for the purpose of the disposal of this complaint and is being reproduced as under;-
3.That the present complaint is completely frivolous and devoid of any merits as the claim of the complainant has already been processed and released as per terms and conditions of the policy, exclusions and the GIPSA (General Insurance Public Sector Association) PPN guidelines and thus has been settled accordingly. Further besides the applicability of the GIPSA as aforesaid, claim f the complainant was decided in terms of policy condition no. 5.12 of the policy. It is submitted that earlier complainant had taken policy for sum insured of Rs.2 Lacs. Complainant was having knee problem for last three years. At that time she was covered under policy with sum insured of Rs.2 Lacs. As such claim of complainant was restricted in accordance with the policy CONDITIONS NO. 5.12 Relevant clause of policy condition is annexed herewith as annexure A. Discharge summary filed alongwith complaint may kindly be considered as annexure b to this reply also. It states about having knee problem for last three years and also disclosed of have paid for last three months i.e. prior to period when the sum insured under this policy has been enhanced for sum of Rs.5 Lacs.
It is submitted that the sum insured for the policy year 31.3.2011 to 30.3.2012 was Rs. 2 lacs. The complainant was having problem of Knee Pain since said year. Latter for the policy period 31.3.2014 to 30.3.2015 the sum insured was enhanced to Rs.5 lacs and within 2 months of enhancement of sum insured complainant got done knee replacement surgery. As such condition no. 5.12 of policy condition was applicable to present case of complainant and claim was approve for Rs.2 lacs in term of the policy conditions only.
It is also imperative to mention here that there was cap on the limit of room charges, doctor ICU charges etc. further certain consumables like gloves, food vitamins etc. are not covered under the policy as such claim was right paid as per policy conditions.
Both the parties have filed their evidence by way of affidavits and have corroborated the contents of complaint and written statement respectively.
We have heard arguments advanced at the bar and have perused the record.
The counsel for the complainant had contended that the OP had not paid the genuine claim of the complainant on false and flimsy grounds. The counsel for the complainant has forcefully contended that the OP company had received the premium of Insurance policy for a sum insured of Rs.5 lakh and as such they are liable to reimburse the claim of the complainant upto Rs.5 lakh.
The counsel for the OP on the other hand has drawn our attention towards clause no. 5.12 of the Mediclaim insurance policy terms and conditions which reads as under:-
5.12 Sum Insured under this policy can be enhanced only at the time of renewal up to next higher slab if Sum Insured under expiring policy is up to Rs.1,00,000 and next two higher slabs if Sum Insured under expiring policy is above Rs,1,00,000 subject to satisfactory medical check up with regard to health of the insured person and acceptance of additional premium for the enhanced sum Insured. However, continuing Aor recurrent nature of diseases/complaints which the insured has ever suffered will be excluded from the scope of cover so far as enhancement of Sum Insured is considered.
He has also pointed out to us the relevant contents of discharge summary which reads as under:-
“Mrs Shanta Jain, 61 year old female presented with complaint of both knee pain for three years..”
The counsel for the OP had drawn our attention towards the copies mediclaim polices attached by the complainant with her evidence, the bare perusal of the same shows that the complainant had enhanced her sum insured in the year 2014-2015 from Rs.2,00,000/- to Rs.5,00,000/-.
In view of the above we are of the considered opinion that the OP had rightly processed the claim of the complainant in terms of policy condition No. 5.12 of the policy.
Since the amount insured had been enhanced in the year 2014, the insured could not have get the benefit of the enhanced amount in view of clause 5.12 of the policy. We therefore see no merits in the complaint the same is hereby dismissed.
Copy of the order be made available to the parties as per rule.
File be consigned to record room.
Announced in open sitting of the Forum on.....................
