On 30.11.2018 the complainant has filed the complaint u/s.12 of the Consumer Protection Act 1986 against the O.P. Nos.1 & 2.  

The case of the complainant in brief, is that, the complainant got mediclaim insurance policy from the O.P under the scheme of “Happy Family Floater 2015 and his policy number was 313501/48/2018/2760 and sum insured was amounting to Rs.15,00,000/- which was commenced from 24.03.2018 and valid up to 23.03.2019. During course of the policy he was admitted in Healing Hands Clinic for his medical treatment of (i) High Fistulectomy + Primary Closure of Internal Opening + Sphincter Repair, (ii) Stapler Haemorrhoidopexy + Transanal  Mucopexy, (iii) Drainage of Abscess Done Under Anaesthesia. Operation was held over there after admission on 12.04.2018 and was discharged on 13.04.18. He expended total Rs.2,32,951/- as doctor fees, hospitalization charge and expenses for medicine. The complainant submitted his claim along with original bills and vouchers before O.P.No.1 and ultimately the O.P paid Rs.1,42,101 to him. Then he again and again requested the O.Ps to make further payment of balance amount of Rs.90,850/- after deducting the amount of Rs.1,42,101/-, but the O.P refused to pay the same. Accordingly, on 01.10.2018 he sent an Advocate’s letter to the O.Ps which is received by the O.P. But the O.P

 did not take any action for payment.

Upon this back ground the complainant prays for a direction upon O.P.Nos.1 & 2 to pay Rs.90,850/-, compensation of Rs.50,000/- and litigation cost of Rs.10,000/-.

Inspite of having service of notice upon the O.P.No.2 he did not come to contest the case and accordingly the case is heard ex parte against him.

The O.P. No.1 has contested the case by filing written version against the complaint denying all the material allegation contending inter alia that the case is not maintainable in its present form and prayer and that the complainant has no cause of action for the case.

The specific case of the O.P. No.1 is that, complainant claimed Rs.2,32,951/- including the discount of Rs.14,313/- which he has not entitled. The complainant is a consumer under him and the O.P.No.1 has paid Rs.1,42,101/- to the complainant instead of Rs.2,20,800/- after deducting the discount of Rs.14,313/- and he placed a chart comparing the various charges of the same disease of the treatment of separate patient in the same hospital which was under value of the charges already paid by the complainant and according to provision of para 1.1 and para 1.2 of Happy Family Floater policy 2015 the said payment was not reasonable and customary charges and according to comparing chart he is only entitled to get Rs.1,42,101/- which has been paid to him. As the complainant has filed this false case with ill intention he is not entitled to get any additional amount and compensation with litigation cost from the O.P and the case is liable to be dismissed.

                                                                  Decision with reasons

In order to prove the case the complainant has examined himself as P.W.1 and filed some Xerox copy of documents i.e discharge certificate, bills and vouchers and policy copy. The O.P. No.1 has examined the Branch Manager of the Oriental Insurance Co. Ltd, Raiganj Branch as O.P.W.1 and he also filed some documents including the discharge card and payment receipt of the complainant. He also filed the Xerox copy of bill and discharge summary of Dr. Dipak Yadav and in respect of one patient of Chandra Kath Sonawane in support of the comparing charge of the patient as mentioned in the W.V and deposition of O.P.W.1.

Admittedly the complainant got medical insurance policy amounting to Rs.15,00,000/- under the scheme of Happy Family Floater 2015 and he was medically treated in the Healing Hands Clinic and the operation of the complainant was done there in respect of the above mentioned diseases and he spent Rs.2,32,951/- including the discount of Rs.14.313/-. Thereafter, he claimed the said amount from the O.P.No.1 and the O.P.No.1 paid Rs.1,40,101/- to him. But the O.P. refused to pay make payment of Rs.90,850/- on the ground that he did not follow the reasonable and customary charges as mentioned in the Happy Family Floater 2015 and he placed the charges of one Dr. Dipak Yadav and Chandra Kant Sonawane for the operation of Fistulainano  and Abscess for which the same hospital received less amount of charges  than the charges claimed by the complainant. Both the evidence of both the parties is the statements in support of their cases depicted in the complaint and W.V. But according to India Medical Council (Professional conduct and ethics) Regulation 2002 when the doctor will treat another doctor as patient or his near family members it would be joyful to him to treat them on free of cost. Therefore, in the instant case the hospital authority ( Private hospital) may take lesser charge of Dr. Dipak Yadav for his treatment. The hospital authority may take charge of other patient according to rules and regulations of the hospital and gravity of the disease and variety of the disease. In the instant case the complainant suffered three types of disease which was operated and he also paid the medical expenses which is totally separate and cannot be compared with other patient. The O.P.No.1 could not produce any document or any other evidence to show that the complainant did not pay the said actual charges to the hospital authority i.e to the Healing Hands Clinic.

On the other hand the complainant proved his case by way of bills, vouchers and discharge summary that he has paid the said amount for his medical treatment and the document has produced by both of them in support of the medical treatment of the complainant show that the Healing Hands Clinic received the said amount from the complainant. Therefore, the O.P cannot deny the payment of medical claim of the complainant on the ground that the hospital authority received the lesser amount of charges from other patient which is baseless and lame excuse. On the other hand the insurance policy was covered of Rs.15,00,000/- and there is no dispute in between the parties and the operation was done during the coverage period of the insurance policy. But the complainant claimed the amount of medical expenses including the discount amount which is not his entitlement. After deduction of Rs.14,330/- from claim Rs.2,35,113/- is Rs.2,20,800/-. The O.P has paid Rs.1,42,101/- and as such the balance amount  of Rs.78,699/- was due to the complainant and the O.P did not pay the same on the above very flimsy ground which cannot be entertain at all. Without making payment of the said rupees when the policy was covered by Rs.15,00,000/-, the O.P committed harassment for which the complainant suffered mental agony and the complainant was compelled to file the case for recovery of the same by the from the O.P and as such he is also entitled to get litigation cost.

Under the above facts and circumstances and foregoing discussion we are of opinion that the complainant is entitled to get Rs.78,699/- as balance amount of the claim along with interest at the rate of 6% per annum and compensation of Rs.25,000/- and litigation cost of Rs.5,000/-.  

Hence, it is,      

                                         ORDERED

That the complaint case be and the same allowed against the O.P.No.1 on contest and ex parte against O.P.No.2.

The O.P.No.1 is directed to pay Rs.78,699/- to the complainant along with interest at the rate of 6% per annum from the date of filing of this case i.e 30.11.2018. The O.P.No.1 is also directed to pay compensation of Rs.25,000/- and litigation cost of Rs.5,000/- to the complainant.

The O.P.No.1 is also directed to pay the whole amount by an account payee cheque in the name of complainant within one month from the date of this order failing which the amount shall carry further interest of 6% per annum till realization.

Let the certified copy of this order be given to the parties free of cost.