1. The complainant has filed the present complaint under the Consumer Protection Act against the opposite parties on the averments that the complainant is a regular customer of Oriental Insurance Company and obtained individual mediclaim policy from the company for last ten years regularly. Last time the complainant obtained mediclaim policy on 28.9.2013, which was valid upto 27.9.2014 for reimbursement of expenses against the risk coverable for illness/disease or injury sustained and surgical for himself for the sum of insured of Rs.3,00,000/- and for his wife Harash Trehan for the sum of Rs.3 Lacs vide policy No.233106/48/2014/342. The complainant had to get a surgical operation from Alchemist Hospital Ltd, Section 21, Panchkulla on 17.4.2014. The complainant had borne hospitalization expenses amounting to Rs.1,93,900/- upon the said surgery and the intimation regarding the said surgery was also given to the company i.e opposite parties. But the opposite parties have paid only Rs.1,57,500/- out of the total amount i.e Rs.1,93,900/- to the hospital but rest of the amount was not reimbursed by the company. It is pertinent to mention that after discharge from the hospital, the complainant was advised by the doctor to have medicine and physiotherapy as per discharge sheet. Upon which the complainant had to pay Rs.13,428/- except the hospital bills. So the total expenses of the complainant upon the said surgery became Rs.2,07,328/- out of which the opposite parties has paid Rs.1,57,000/- only and the remaining amount of Rs.49828/- was not paid by the opposite parties. The complainant vide letter dated 12.6.2014 requested the company to pay the remaining amount of Rs.49828/-. The complainant also sent the bills regarding the expenses borne by the complainant to the opposite parties, but the opposite parties vide letter dated 7.7.2014 has refused to pay the rest of the amount to the complainant. Thereafter the complainant again issued a letter dated 8.9.2014 to the opposite parties with a request to reimburse the amount which was paid by the complainant from his own pocket to the hospital but till date the opposite parties have neither replied the said letter nor paid any amount to the complainant. On such like averments, the complainant has prayed for directing the opposite parties to pay him Rs.49,828/- alongwith interest. He has also claimed compensation and litigation expenses.

2. Upon notice, opposite parties No.1 to 3 appeared and filed a written reply pleading that the complainant is guilty of concealment of material facts as he has not come before this Forum with clean hands and has twisted and misrepresented the true facts. As such the complainant is not entitled to any relief from this Forum. During the course of his treatment it has come out that complainant availed the high class facility etc as per his own capacity and visiting consultations, which was beyond the package agreement of GIPSA with that hospital for the treatment of disease of complainant, which is not covered under the policy. In this way there is no deficiency of service or unfair trade practice on the part of the answering opposite parties. The replying opposite parties vide its letter dated 7.7.2014 provide the final settlement detail to the complainant. The complaint has been filed with malafide motive, is liable to be dismissed. The claim of the complainant is beyond his medical package. They denied other material averments of the complainant.

3. Opposite party No.4 did not appear inspite of notice and as such it was proceeded against exparte.

4. In support of his complaint, learned counsel for complainant has tendered affidavit Ex.CA alongwith copies of documents Ex.C1 to C18 and closed evidence.

5. On the other hand, learned counsel for opposite parties No.1 to 3 has tendered affidavit Ex.OP1to3/A alongwith copies of documents Ex.OP1to3/1 to Ex.OP1to3/3 and closed evidence.

6. We have carefully gone through the record and also heard the learned counsels for the parties.

7. The facts involved in the present complaint are not much disputed. It is not disputed that complainant had obtained mediclaim insurance policy from the opposite party insurance company. The complainant under went surgical operation in Alchemist Hospital Ltd, Sector 21, Panchkulla on 17.4.2014 and paid Rs.1,93,900/- to the hospital. Ex.C5 is patient bill. Out of the above said amount, the opposite party insurance company only paid Rs.1,57,500/- to the complainant. So in this way, opposite party insurance company paid Rs.36,400/- less to him. This fact is evident from the patient bill Ex.C5. Counsel for the opposite parties contended that as per Gipsa Agreement between insurance company and the hospital, the complainant was only entitled to Rs.1,57,500/-. We have carefully considered the above contention advanced by learned counsel for the opposite parties. The Gipsa agreement was between the opposite party insurance company and the hospital and the complainant was not party to it nor the same was made part of the policy. So the same is not binding on the complainant. In patient bill Ex.C5 Gipsa-Total Knee replacement is mentioned and the rate is mentioned as Rs.1,92,500/-. So even as per patient bill Ex.C5, the amount charged by the hospital was as per Gipsa agreement. The opposite parties have placed on record Memorandum of Understanding Ex.OP1to3/3 which is between the hospital and the insurance company through TPA. Even as per clause 4.7 where expenses exceed the pre-defined package, the provider will inform the patient/relatives that these expenses will not be reimbursed by TPA/insurer under their policy and take written confirmation from the patient/relative to this effect. In case of non compliance and if such amounts are claimed by the insured person, such amount may have to be borne by the provider i.e hospital. In the present case, opposite parties No.1 to 3 have not led evidence that the hospital took any written confirmation from the patient/insured that the amount paid by him is in excess of the package as per Gipsa agreement. So if the hospital has violated the agreement between the insurance company and hospital then insurance company may recover excess amount from the hospital as per above clause of memorandum of understanding. Moreover the Gipsa agreement was not made part of the policy nor the hospital took any written confirmation from the insured that amount to be charged by the hospital was in excess of Gipsa agreement or package. So in these circumstances, the opposite party insurance company is liable to pay remaining amount of Rs.36,400/- which was deducted by the opposite party insurance company from the total bill amount of Rs.1,93,900/-. The opposite parties have placed on record terms and conditions of mediclaim insurance policy. Condition No.2.4 of the terms and conditions of the mediclaim insurance policy defines domiciliary hospitalization benefit. It lays down as under:-

"2.4 Domiciliary Hospitalization Benefit:- means medical treatment for a period exceeding three days such illness/disease/injury which in the normal course would require care and treatment at a hospital/nursing home as in-patient but actually taken whilst confined at home in India under any of the following circumstances namely:-

1. The condition of the patient is such that he/she can not be removed to the hospital/nursing home.

2. The patient can not be removed to hospital/nursing home due to lack of accommodation in any hospital in that city/town/ village".

8. So as per above clause domiciliary hospitalization benefit means any medical treatment for a period exceeding three days which in the normal course would require treatment in a hospital as in-patient but is actually taken whilst confined at home in India on the ground that condition of the patient is such that he/she can not be removed to hospital/nursing home. So the complainant is not entitled to domiciliary hospitalization benefit as he was admitted in the hospital as in patient.

9. In view of above discussion, the present complaint is partly accepted and opposite parties No.1 and 2 are directed to pay Rs.36,400/- to the complainant alongwith 9% interest from the date of filing of the present complaint till payment. Complainant is also awarded Rs.5000/- in lump sum on account of compensation and litigation expenses. Copies of the order be sent to the parties free of costs under the rules. File be consigned to the record room.