O R D E R
SUBHASH GUPTA
The present complaint has been filed by the Complainant against the O.Ps under section 12 of Consumer Protection Act, 1986 hereinafter to be referred as the ‘Act’. The facts as alleged in the complaint are that the complainant had taken a mediclaim policy (Happy Family Floater Policy) bearing No.271500/48/2012/5271 for the period from 3.02.2012 to 2.02.2013. It is alleged that five family members are covered in this policy including the complainant. It is alleged that the complainant took treatment for Enteric Fever with Acute Urinary Tract Infection from Ekansh Nursing Home and remained admitted in the nursing home w.e.f. 15.5.2012 to 23.5.2012. It is alleged that complainant spent a sum of Rs.88,169/- on his treatment. It is further alleged that complainant submitted all the relevant documents with bills to the O.P-2 on 26.5.2012 seeking the reimbursement of the same. It is alleged that to the utter surprise of the complainant he received a cheque of Rs.65,397/- only instead of Rs.88,169/-. It is further alleged that on 15.9.2012, the complainant sent a letter to both the OPs against the deduction of Rs.22,772/- but no reply has been received till date in this regard. It is alleged that it is crystal clear that the OPs have no intention to pay the aforesaid amount to the complainant. The complainant vide the present complaint has claimed a sum of Rs.22,772/- alongwith interest @ 18% p.a. The complainant has also claimed a sum of Rs.50,000/- towards compensation for harassment caused to the complainant by the negligence, deficiency in service and conduct of OPs and Rs.25,000/- towards cost of litigation.
2. OP-1 appeared and filed its written statement. In the written statement O.P-1 has not disputed the existence of the policy referred to above. OP-1 has further stated that the complainant submitted his claim for a total sum of Rs.88,169/- towards his medical expenses etc. It has been alleged that after receiving the claim intimation, the OP-1 appointed M/s E-Meditek (TPA)Service Ltd. i.e. OP-2, as the 3rd party Investigator to investigate and to settle the claim of the complainant. Accordingly a sum of Rs.65,397/- was paid by the OPs towards the settlement of the claim of the complainant. It has been pleaded that the rest of the amount was not payable as per the terms and conditions of the insurance policy. It has been pleaded that during the hospitalization, a sum of Rs.5, 000/- per day was charged towards room rent and Rs.1000/-per day was charged towards nursing charges. It has been pleaded by the OP that the charges of the hospital was towards higher side as it was revealed that while settling the claim with the New India Insurance Company, the same hospital has charged a sum of Rs.4000/-per day as room rent and nursing charges. It has been pleaded that a sum of Rs.32000/- was settled by the TPA for 8 days @ Rs.4000/-per day. It has been pleaded that a sum of Rs.13,800/- was paid by the TPA towards consultation charges against the claim amount of Rs.14,600/- as the complainant was admitted in the hospital on 15.5.2012 at 4 p.m. and he was discharged on 23.5.2012 at 11 a.m., therefore he was only entitled for 2 visits of the doctors per days i.e 16 visits during hospitalization @ Rs.800/-per visit. It has been pleaded that a sum of Rs.1,000/- was also paid as per bill dated 4.5.2012 and 14.5.2012 towards consultation charges @ Rs.500/-per consultation and a sum of Rs.372/- was deducted towards the claim amount as the amount of Rs.372/- was raised towards purchase of article “Intra cath and prime Fix”. It has been further pleaded that the said amount was under the category of non-payable items as per opinion given by the TPA. It has been also pleaded that out of total claim amount of Rs.88,169/- a sum of Rs.65,397/- was payable and the rest of the amount was not payable to the complainant. Therefore, there is no deficiency of service on the part of OP-1 and the complainant is not entitled for any claim/relief. Dismissal of the complaint has been prayed for.
3. Complainant has filed his affidavit affirming the facts alleged in the complaint. On the other hand Mr. Brij Mohan, Sr. Dvisional Manager has filed affidavit in evidence on behalf of O.P-1 and Sh. Sunil Kumar, Representative of TPA has also filed affidavit for testifying all the facts as stated in the written statement. Parties have also filed their respective written submissions.
4. We have carefully gone through the record of the case and have heard submissions of complainant and Ld. Counsel for the O.P. OPs have admitted existence of the policy and have also paid a substantial amount of the claim raised by the complainant. The claimed amount in this case is the remaining balance amount of Rs.22,772/- only. The plea taken by the OPs in this regard is that the same nursing home while settling one of the claim with New India Insurance Company has charged Rs.4000/-per day towards the same room as room rent and nursing charges. Accordingly, the OPs have made the deductions. It will be pertinent to note that the OPs have failed to produce any document to substantiate the averments raised in the written statement as well as affidavit. The OPs could have easily filed the settlement claim of the other Insurance Company on which it’s relying. In such circumstances in absence of any documentary evidence, the oral averments cannot be relied upon.
5. In view of this fact, we are of the considered view that the OPs were deficient in not reimbursing the total claimed amount of the complainant in respect of medical expenses incurred by him. Accordingly, we direct the OPs to pay a sum of Rs.22,772/- which is the remaining claimed amount. Complainant is also awarded a sum of Rs.3,000/- towards compensation which will also include cost of litigation.
Copy of this order be sent to the parties as per rules.
Announced this 18th day of April, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
