Sri C.V.MARAGOOR,

President

1.       This complaint has filed by Miss.Savithri.M.L.                 D/o late Lakshmaiah.M.V aged 48 years to direct the opposite party to pay Rs.15,487/- and damages of Rs.25,000/- with interest at the rate of 18% p.a. on the delayed payment.
2.       The opposite party No.1 is S.B.I General Insurance Company Limited, Mysuru and opposite party No.2 the Assistant General Manager, SBI Main Branch, Mysuru.  The complainant has maintained S.B. account in S.B.I. J.S.S. Layout, Mysuru City and obtained health insurance policy for a sum of Rs.1,00,000/- from the opposite party No.1 through opposite party No.2.  The initial policy was for the period from 02.11.2015 to 01.11.2016 and it was renewed on 15.11.2016 by paying Rs.2,600/- which was debited to her S.B. account.
3.       The complainant has admitted to Apollo BGS Hospital at Mysuru on 30.04.2017 for acute gastro-entritis and she was discharged on 02.05.2017.  The policy of the complainant was cashless policy as such, the opposite party No.1 has initially sanctioned Rs.5,500/- and on 25.09.2017 credited Rs.3,210/- to her account when she perused the matter under the Right to Information Act.  The opposite party No.1 has paid a total sum of Rs.8,710/- as against the actual bill of Rs.22,001/-.  The opposite party No.1 out of post hospitalization expenses of Rs.4,099/- has paid only Rs.1,902/-.  Though the complainant has got issued legal notice to the opposite parties on 26.10.2017 neither paid the balance bill amount nor replied to the notice.  Hence, this complaint for deficiency in service on the part of opposite parties.
4.       The opposite party No.1 appeared through its learned counsel and filed written version admitting that medical health policy obtained by the complainant was valid on the date of hospitalization and illness.  The opposite party No.1 further admitted that the complainant was admitted to Apollo B.G.S Hospital, Mysuru on 30.04.2017 and discharged on 02.05.2017.  The complainant was treated conservatively for acute gastro-entritis during admission.  Considering the time frame, the opposite party deducted one day extra bed charge, nursing and RMO charge as such paid Rs.5,500/-.  The complainant is not entitled for total bill amount of Rs.22,001/- and non-admissible amount is Rs.16,306/- and after admitting non-admissible from the total bill the opposite party No.1 has made payment of Rs.5,500/-.  Further, the opposite party No.1 has paid another sum of Rs.3,210/- considering number of days complainant was hospitalized and the total bill received by it.  The opposite party No.1 has not disallowed post hospitalization expenses.  The next contention of opposite party No.1 is that the complaint is bad for non-joinder of TPA M/s Medicare TPA Pvt. Ltd., who processed the claim of the complainant considering the terms and conditions of the policy and medical records.  On the above grounds, the opposite party No.1 asked to dismiss the complaint.
5.        In spite of service of notice opposite party No.2 absent consequently it is placed exparte.
6.        The complainant filed her affidavit in lieu of evidence and produced 14 documents in support of her case. On behalf of opposite party No.1 one Miss Madhavi Uttam Patil filed her affidavit and produced two documents.
7.         We have heard the arguments advanced by the learned counsel for both the parties in addition to written brief submitted by the complainant and opposite party No.1 and the points that would arise for determination are as under:-  

1. Whether the complainant proves that the act of opposite party No.1 rejecting part of the medical bill payment amounts to deficiency in service and unfair trade practice?
2.  Is complainant entitled to the reliefs sought for?

8.         Our findings on the aforesaid points are as follows:

Point No.1:- In the affirmative;

Point No.2:- Partly in the affirmative as per final order for the following

:: R E A S O N S ::

9.           Point Nos.1 and 2- The learned counsel for the complainant has submitted that the opposite party No.1 has initially sanctioned only Rs.5,500/- during the hospitalization.  Later on when the complainant has sought information under Right to Information Act credited Rs.3,210/- to her S.B. account during the pendency of this case.  The learned counsel for the opposite party No.1 has urged that some assured opted by the complainant is Rs.1,00,000/- and member is eligible for room + nursing + RMO limit at 1% sum assured as Rs.1,000/- per day.  If opted for higher room then proportionate clause will be applied as per policy terms and conditions.
10.       The opposite party No.1 has not disputed that the complainant had obtained health insurance policy and the same was renewed on 15.11.2016.  The opposite party No.1 has not disputed hospitalization of the complainant at Apollo BGS Hospital, Mysuru for acute gastro-entritis on 30.04.2017 and discharged on 02.05.2017.  The complainant and opposite party No.1 produced final bills issued by Apollo BGS Hospital, Mysuru for Rs.22,001/- in addition to that post hospitalization expenses of Rs.4,099/-.  The opposite party No.1 admitted that it has not paid entire bill amount.  The opposite party No.1 has not produced health insurance policy which contained terms and conditions to know which are inadmissible items of the bill.  The opposite party No.1 without any basis has disallowed Rs.13,290/- out of the Apollo BGS Hospital bill amount and Rs.3,007/- post hospitalization charges.  The opposite party has not produced any document in support of their defence to reject the hospitalization expenses supported by the medical bill issued by Apollo BGS Hospital, Mysuru and post hospitalization charges.  The TPA is neither necessary nor proper party since it is an agreement between the opposite party No.1 and TPA to process the medical claims of the insured.  The complainant is no where concerned with the agreement between the opposite party No.1 and TPA.
11.       The opposite party No.1 has credited Rs.3,210/- after this complaint to the account of complainant though the complainant had submitted claim application before filing the complaint. This shows that the opposite party No.1 has played unfair trade practice by rejecting the mediclaim of the complainant.  Therefore, now the complainant is entitled for medical bill amount a sum of Rs.15,487/- since already the opposite party No.1 has paid Rs.8,710/-.  The complainant has not produced any material for award of damages of Rs.25,000/-.  The complainant has suffered mental agony since the opposite party No.1 has rejected part of the medical bill amount as such she is entitled for compensation of Rs.5,000/- in addition to litigation costs of Rs.10,000/-. Accordingly, we proceed to pass the following;        

:: ORDER ::

1. The complaint filed by Miss Savithri.M.L. is partly allowed directing the opposite party No.1 to pay a sum of Rs.15,487/- to the complainant with interest at the rate of 10% p.a. from 02.05.2017 till payment.
2. It is further ordered that the opposite party shall pay Rs.15,000/- towards compensation and litigation costs to the complainant within 30 days from the date of order. Otherwise, it carries interest at the rate of 10% p.a. from the date of filing complaint till payment.
3. Complaint is dismissed against opposite party No.2.
4. Furnish the copy of order to the complainant and opposite parties at free of cost.