Order-16.
Date-15/12/2015.
In this complaint Complainant Nawal Kishore Agarwal by filing this complaint has submitted that complainant took Hospitalization Policy being No.101100/48/11/8500006729 dated 12.11.2010 by paying requisite premium net Rs. 25,670/- on 04.10.2010 for the period of 11.10.2010 to 10.10.2011 covered to the sum insured of Rs. 4,00,000/- plus cumulative bonus of Rs. 1,00,000/- totaling sum of Rs.5,00,000/- from the op.
Complainant renewed the said hospitalization benefit policy without any break vide Policy No.101100/48/11/8500006890 dated 30.09.2011 by paying the requisite increased premium of Rs. 26,314/- for the period of 11.10.2011 to 10.11.2012 for the sum insured of Rs. 4,00,000/- plus cumulative bonus Rs. 1,20,000/- totaling a sum of Rs. 5,20,000/- from the op.
Again complainant renewed the said hospitalization benefit policy without any break vide Policy No. 101100/48/12/8500007264 by paying the requisite premium of Rs. 26,314/- for the period from 11.10.2012 to 10.10.2013 for the sum insured of Rs. 4,00,000/- plus cumulative bonus of Rs. 1,20,000/- from the op.
Complainant faced a tragic road traffic accident at Rajasthan and attacked severally with fracture dislocation of right hip and the complainant was immediately admitted at Fortis Flight LequenantRajanDhall Hospital on 22.08.2011 due to critical condition and he was diagnosed there as case of Fracture dislocation of right hip with upper tibia stein pin in situ for skeleton traction and necessary treatment was done and he was discharged on 07.09.2011 and for such treatment complainant spent a sum of Rs. 3,35,000/- and that was settled by the Insurance Company and a sum of Rs. 3,06,109/- only by the ops under Insurance Policy No. 101100/10/800006729 for the period 11.10.2010 to 10.10.2011.
Subsequently on 18.08.2012 complainant became unconscious due to terrible/unbearable pain in the right hip and was examined by his family physician who advised to contact Dr. J. Thakkar, Surgeon at Mumbai in Breach Candy Hospital who was specialized in total hip replacement and on the advice of Dr. C.J. Thakkar dated 11.09.2012 complainant took admission at Breach Candy Hospital, Mumbai on 11.09.2012 for surgery on 14.09.2012 and in the said hospital complainant admitted on 11.09.2012 and discharged on 04.11.2012 and total hip replacement done on 14.09.2012 by the said Dr. C.J. Thakkar.
At the time of discharge, complainant paid a sum of Rs. 21,98,936/- only to the said Breach Candy Hospital being the entire expenditure of treatment of hip replacement which occurred due to road traffic accident at Rajasthan.After returning from Breach Candy Hospital complainant was bed-ridden till 01.01.2014 as continues operative treatment was going on under the supervision of Dr. Sanjoy Kumar Sahthaliaand ultimately on 02.01.2014 complainant’s family Dr. Sanjoy Kumar Santhalia declared the complainant fit and certified that the complainant can attend for office work.
Thereafter complainant lodged the Mediclaim and submitted claim form to the ops on 15.01.2014 for reimbursement of Medical expenditure incurred by the complainant for hip replacement at Breach Candy Hospital at Mumbai and complainant claimed a sum of Rs. 22,09,785/- only jointly under two policies in continuation and the complainant submitted detailed statement of expenditure incurred on account of pre-hospitalisation, during hospitalization and post hospitalization for hip replacement surgery.
On 14.01.2014 complainant narrated the entire facts along with reasons for delay in lodging the mediclaim and also requested the ops to condone delay and to reimburse the medical expenditure incurred during the policy period 2011to 2012 and 2012 to 2013.By a letter dated 22.10.2014 complainant further requested the ops to settle the claim at the earliest as the matter is still as it is condition and nothing has been heard as yet and against that op’s head office by letter dated 17.11.2014 acknowledged the letter of the complainant dated 22.10.2014 and advised to provide the contact number to enable them to proceed further in the complainant’s case.
But thereafter op nos.1 & 2 did not take any positive steps in settling the mediclaim of complainant, complainant further by a letter dated 09.02.2015 requested the op no.1 to process the claim at the earliest.Though ops received the relevant original documents, but did not promote to settle down the legitimate mediclaim of complainant amounting to Rs. 10,40,000/- being the sum insured of Rs.5,20,000/- only for 2011 to 2012 and Rs. 5,20,000/- for 2012-2013 and sat tight without disposing of the same and for the reason best known to them.
Though complainant spent Rs. 21,98,936/- for his hip replacement surgery at Breach Candy Hospital at Mumbai but only claimed a sum of Rs.10,40,000/- only being the sum insured as per terms and conditions of the policies but the ops intentionally without any reasons withheld the entitled mediclaim amount Rs. 10,40,000/- illegally and has been harassing the complainant in so many manner and for which it is no doubt a deficiency of service for which complainant has filed this complaint praying for redressal and for directing the op to pay Rs. 10,40,000/- and compensation, interest etc.
On the other hand op by filing written version submitted that op wrote letter to the complainant on 10.12.2014 seeking clarification from the complainant that claim documents was submitted after more than fourteen months from the date of discharge which is in violation of policy condition. No satisfactory clarification was given by the complainant. So, there was no deficiency on the part of the op.Further submitted that the policy condition shall be strictly followed by the Forum and no exception and relaxation can be made on the ground of equity and at the same time for violating the terms and conditions, complainant is not entitled to get any relief.
Moreover from the FIR, it is not apparent and there is no such document to show that driver had a valid driving license and address of the vehicle owner is also not there and it is also not noted whether any case is filed against the vehicle owner and many other things that may be required for settling the claim.Further op submitted that complainant had policy amounting to Rs. 5,00,000/- and in malafide intention and to drag the matter in two consecutive year claimed of Rs. 10,00,000/- and on preliminary scrutiny, it appeared that the ops wrote a letter to the complainant on 10.12.2014 seeking clarification from the complainant why claim documents was submitted after more than 14 months from the date of discharge which is in violation of policy condition and in the above circumstances the present complaint is not tenable.
Further it is submitted that complainant did not report the matter of accident about his admission and date of his discharge within 7 days from the date of hospitalization or domiciliary hospitalization etc.But claim was submitted after lapse of 14 months from the date of his discharge and unsatisfactory clarification was made by the complainant against that letter sent by the ops.But ultimately ops wrote letter to the complainant on 10.12.2014 seeking clarification but that was also not answered.
So, in the above circumstances, the claim of the complainant cannot be disposed of but it is still pending for submitting clarification sought for by the ops and in the above circumstances the complaint should be dismissed.
Decision with reasons
On proper consideration of the complaint and written version and also hearing the Ld. Lawyers of both the parties and further the Clause 5.3 of the policy, it is clear that upon the happening of any event, which may give rise to a claim under this policy notice with full particulars shall be sent to the Company within 7 days from the date of injury/hospitalization/domiciliary Hospitalisation etc.
But most interesting factor is that complainant claimed that he faced road accident on 21.08.2011 and for that purpose he was admitted to the Hospital and necessary treatment was done and was discharged on 07.09.2011 and in respect of that treatment, complainant paid Rs. 3,35,000/- and submitted claim and a sum of Rs. 3,06,109/- was paid by the op under Insurance Policy No.101100/10/800006729 for the period 11.10.2010 to 10.10.2011.So, it is clear that in respect of the road accident when complainant was hospitalized and treated the said claim was settled against Policy No. 101100/10/800006729 for the period 11.10.2010 to 10.10.2011 and in respect of that there is no fault so that the allegation of the complainant that op did not consider any claim is not at all true.
On proper consideration of the complainant and also the document filed by the complainant, it is clear that complainant claimed a sum of Rs. 22,09,785/- and it was submitted by the complainant to the ops for the treatment cost for the period from 11.09.2012 to 04.11.2012 along with documents.
So, considering the period of treatment, it is clear that complainant did not inform the ops about hospitalization about treatment, about operation etc. within 7 days from the date of discharge that is 04.11.2012 but said claim submitted and same was admitted by the op on 14.01.2014 that is long after 14 months and that was received along with prayer for consideration for delay.But op specifically has proved that inspite of accidental injury, op already paid a sum of Rs. 3,06,109/- to the insured.But it is the subsequent operation and actually complainant claimed Rs. 22,00,000/- and odd in the claim petition.But in respect of Policy No.101100/10/800006729 for the period 11.10.2010 to 10.10.2011complainant is not entitled to get any benefit of the said policy because said policy was valid up to 10.10.2014 and they cannot approve the complainant’s claim of Rs. 2,00,000/- and odd for his treatment from 11.09.2012 to 04.11.2012 and only in respect of policy No.101100/48/12/8500007264 for the period from 11.10.2012 to 10.10.2013 no doubt complainant ought to have filed claimbut by clubbing both the insurance policies, complainant has filed a mediclaim of Rs. 22,09,785/- but in the complaint, complainant has prayed for a sum of Rs. 10,40,000/-.But complainant submitted the claim for disbursement for a sum of Rs. 22,09,785/- when that is the fact, then it is found that the entire claim as submitted before the op for disbursement isRs. 22,09,785/- on the basis of the claim application, complainant has filed a complaint and prayed for releasing of Rs. 10,40,000/- but rule is that it cannot be taken in to account for deciding the pecuniary jurisdiction of this Forum.But the pecuniary jurisdiction shall be based on actual claim and as per claim application Annexure-I, Page-44, it is found that complainant submitted a claim for Rs. 22,09,785/- to the op and if we consider the entire consumer dispute i.e. said claim dated 14.11.2014 for amount of Rs.22,09,785/- and what that is the fact, then it is clear that the pecuniary jurisdiction shall be decided on the basis of the original claim application and also on the basis of the admission of the complainant as made in para-14 of complaint.
But as per law, this Forum has no authority to decide any consumer dispute related to a value of Rs. 22,09,785/- but in respect of the dispute about Rs. 22,00,000/- it shall be decided by the Hon’ble State Commission not by this Forum.
Ld. Lawyer for the complainant submitted that admitted position is that complainant submitted mediclaim form for a sum of Rs. 22,08,785/- but they are not claiming the said amount but claimed to the extent of Rs. 10,40,000/- and in respect of that complainant prayed for relief.So, this Forum has jurisdiction but Ld. Lawyer for the op submitted that the entire dispute depends on the original claim application.Complainant has admitted that he prayed for disbursement a sum of Rs. 22,00,000/- and odd.So, this Forum has no jurisdiction.After giving anxious thought in respect of the plea of the complainant, we are of the view that the said relief as claimed in this case cannot be taken into account for considering the pecuniary jurisdiction though complainant’s Ld. Lawyer submitted that Pecuniary jurisdiction shall be deicded on the basis of the relief as prayed for,so the present Forum has jurisdiction to decide this complaint.
But after considering the final documentthe claim application which is the subject matter of the dispute which was submitted by the complainant on 14.11.2014 and complainant also admitted in para-14 that he submitted mediclaim for a sum of Rs. 22,09,785/- we are convinced that the said document is itself for deciding the consumer disputes, may be complainant at this stage before this Forum prayed for relief in respect of decreased amountof mediclaim of Rs. 10,40,000/- in place of their actual claim of Rs. 22,09,785/-.But it must be kept in our mind that the entire dispute is related the mediclaim submitted by the complainant on 14.11.2014 and that claim is in respect of Rs. 22,09,785/-.No modified application had been filed by the applicant before the op by reducing his mediclaim to the extent of Rs.10,40,000/- to the ops authority.
So, under any above circumstances, complainant cannot pray for any relief outside the actual claim as submitted by him to the op and considering the legal aspect and also the principle of deciding the pecuniary jurisdiction of this Forum, we have gathered that the entire dispute arose from the claim application submitted by the complainant for a sum of Rs.22,09,785/- and that amount no doubt exceeds the jurisdiction of this Forum because this Forum can decide any dispute in respect of any actual claim prayed before any authority upto twenty lakhs only and when that is the legal position, then it is clear that mediclaim application was submitted by the complainant for a sum of Rs. 22,09,785/- and that has not been disposed of for many reasons and also on the ground that complainant did not file some clarification and documents as per requirement of the op, though op reported the complainant by a letter dated 10.12.2014. Complainant did not file any clarification.At the same time it is most interesting that before filing of this complaint, complainant did not submit any modified claim application for Rs. 10,40,000/- to the ops,but till now that claim application is under the consideration of the op for settlement and that amount is Rs. 22,09,785/-.When that is the fact, then invariably this Forum’s jurisdiction is curtailed for crossing the pecuniary jurisdiction of this Forum when consumer dispute is relatedto Rs.22,09,785/-, but the present Forum’s jurisdiction is up to Rs.20,00,000/-
Considering the above materials and fact, we are convinced to hold that this Forum has no pecuniary jurisdiction to entertain this consumer dispute or the complaint even if complainant at the time of filing, this complainant prayed for releasing a less amount of Rs.10,40,000/- against actual claim of Rs.22,09,785/- but that cannot anyway cure the pecuniary jurisdiction of the Forum because it is principle of law that the document for claim is the subject matter of dispute because that claim has not been disposed of finally by the op as claimed by the complainant.No modified claim has yet been filed by the complainant to the op, for which we are inclined to hold that this Forum has no jurisdiction to entertain such complaint on the ground that this Forum has no pecuniary jurisdiction to decide any such mediclaim for Rs. 22,09,785/- pending before ops.
In the result, this complaint fails on the ground that this Forum has no pecuniary jurisdiction to entertain the present complaint on the ground that the present complaint was filed for disposing of the mediclaim submitted by the complainant on 14.01.2014 for a sum of Rs. 22,09,785/- but not for Rs.10,40,000/- when no such mediclaim application for release of Rs.10,40,000/- is pending before the ops.
In the result, this complaint fails.
Hence, it is
Ordered,
That the complaint be and the same is dismissed on the ground that this Forum has no pecuniary jurisdiction to decide the present mediclaim of the complainant as per his mediclaim application dated 14.01.2014 by which complainant prayed for disbursement of Rs. 22,09,785/-.
