FINAL ORDER/JUDGMENT           

SHRI SWAPAN KUMAR MAHANTY,   PRESIDENT

Brief facts necessary for the adjudication of the present complaint are that complainant and her wife obtained a Family Floater Health Insurance Policy being No. 311100/48/2019/1194 from the OP-1 Oriental Insurance Company Ltd. and the policy was valid from 29.06.2018 to  28.06.2019.  Complainant was admitted to Drishti Daan Eye Foundation on 07.03.2019  and  28.06.2019 for Senile Cataract Surgery within the risk period and incurred medical expenditure during hospitalisation a sum of Rs.  1,20,753/- and Rs. 1,14,348/- respectively including fees of surgeon Dr. Ajay Pal.  Complainant submitted claim to the OP-1 on 20.03.2019 and the OP-2 Vipul Medcorp Insurance TPA Pvt. Ltd. settled the claim to the extent of Rs.  33,144/- and Rs. 36,073/- out of Rs. 1,20,753/- and Rs. 1,14,348/- and credited settled amount to the RIGS bank account of the complainant through NEFT/RTGS. Thus, the OP-1 violated the basic principle of Mediclaim Insurance Policy. On this aspect, complainant filed the case claiming the balance amount.

The complaint is resisted by the OP-1 by filing WV stating that the complaint is not maintainable as liability of the Insurance Company is contractual. It is alleged that Clause No.  3.41 of the policy defines Reasonable and Customary charges which means the charges for services or supplies which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical services, taking into account the nature of the illness injury involved. OP-1 promptly settled the claim in terms of the policy conditions in terms of the policy conditions and remitted the settled amount to the bank account of the complainant through NEFT.  There is no negligence deficiency in service and unfair trade practice on the part of the OP-1/Insurer. The claim is therefore, not payable and ultimately, they prayed for dismissal of the complaint.

Despite service of notice of complaint, OP-2/TPA did not appear to contest the case by filing WV and the case runs ex parte against them.

In support of his case, the complainant tendered his evidence supported by affidavit and also relied the documents annexed with the complaint petition.

To rebut the aforesaid evidence, Divisional Manager of OP-1 has tendered evidence supported by an affidavit along with document as annexure-1.

We have heard the Ld. Counsel for both the parties and have careful gone through the record of the case.

The main grievance of the complainant is that the OPs settled the claim amount to the extent of Rs. 33,144/- and Rs. 36,073/- erroneous out of total claim of Rs. 1,20,753/- and rs.  1,14,348/-. Despite several requests and demand, the OP-1/Insurer reluctant to disburse the balance claim of Rs. 87,609/- and Rs.  78,275/-.

 It is argued on behalf of the OP-1 that the complainant was well aware of the policy terms  & conditions and in terms of Clause 3.41 the complainant is not entitled for difference claim amount. It is further contended that complainant has already received the claim amount as per policy terms & conditions. Thus, the complainant is estopped from raising the question of any further claim against policy No. 311100/48/2019/1194.

Ld. Counsel for the complainant, per contra, submitted that the OP-1 is bound to pay the balance claim amount to the complainant.

On perusal of the documents annexed with the complaint petition,  it appears that the complainant /insured was admitted to B B Eye Foundation for treatment of Senile Cataract Surgery on  07.03.2019 and  14.03.2019 which fell within the policy period from  29.06.2018 to  28.06.2018. The claim for an amount of Rs. 1,20,753/- and Rs. 1,14,348/- was submitted to the OP-1 on  20.03.2019 and an amount of Rs. 33,144/- and Rs 36,073/- was remitted through NEFT/RTGS to the bank account of the complainant against  the said claim. The complainant vide letter dated 17.07.2019 raised objection to that settlement as the insurance company is liable to pay for hospitalisation expenses for medical/surgical treatment taken as an inpatient at any nursing home/hospital in India as defined in the policy. Thus, the OP-1 violated basic principle of Mediclaim Insurance Policy.

Clause 3.41 of the policy defines Reasonable and Customary Charges:  means the charges for services or supplies which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/injury involved the OP-1 settled the claim within 50 days from the date of receiving claim application. Complainant never objected the terms and conditions of the policy and, therefore, cannot raise any objection with regard to the clauses at this juncture.

The terms and conditions of the policy must be given paramount importance and it is not open for substitute any words therein. It is also well settled that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly  construed to determine the extent  of liability of the insurer. Thus, we have no scope to bypass the policy condition under any circumstances. As such,  the OP-1 settled the claim to the extent of Rs. 33,144/- and Rs. 36,073/- out of claim amount of Rs. 1,20,753/- is justified. Insurance claim cannot be allowed de-hors exclusion clause contained in the policy. In our opinion, there is no deficiency in services for settlement the claim of the complainant to the extent of Rs.  33,144/- and Rs.  36,073/- on the part of the OP-1/Insurer. OP-2 Vipul Medcorp TPA Pvt. Ltd. have no liability to pay the claim amount against the Insurance Policy. OP-2 is the authorised agency of OP-1/Insurer to scrutiny the claim on terms of the Mediclaim Policy and settled the claim amount. Thus, the action of OP-2/TPA in settlement the claim did not amount to deficiency in service on their part. In the result, the complainant is not entitled to get any relief as prayed for. Accordingly, we hereby dismissed the consumer complaint on contest against the OP-1/Insurer and also dismissed ex parte against OP-2/ TPA. There is no order as to cost.

The complaint case could not be decided within the stipulated period due to heavy pendency of cases and also due to covid-19 pandemic.

A copy of this judgment be provided to the parties free of cost as mandated by the CP Act, 2019. The Judgment be uploaded forthwith on the website of commission for the perusal of the parties.