This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted that complainant is the holder of a mediclaim policy being No.510100/34/11/01/00010018 from the OP since 20-03-1991 and the last renewal premium paid on 14-03-2012 for sum assured of Rs.1,00,000/- covering a period from 20-03-2012 to 19-03-2013 and complainant no.2 was the beneficiary of that policy.

          During validity of the aforesaid mediclaim policy, complainant no.2 fell ill and was admitted to Uma Medical Institute (P) Ltd., Teghoria, Kolkata – 700 157 on 26-08-2012.

          As the policy was for Rs.1,00,000/- the rule 2.1 of the contract mediclaim (2007) with OP1 allows bed charges Rs.1,000/- per day  at the rate 1percent cover amount.  However, complainant had to obtain a bed with daily charge of Rs.2,500/- and reimbursement only  at the rate Rs.,000/- per day, which means only 40percent of the rent they paid for the said but for that reason they had not aggrieved because they are well aware of the fact of rule 2.1 of the mediclaim policy.  After diagnosis, operation and treatment complainant no.2 was discharged on 28-03-2012 and hospitalization was duly intimated to the OP2 and the claim form was duly filled up and signed by the complainant and claim was registered as T121112628 and the complainant received a cheque No.973212 dated 30-11-2012 for Rs.16,000/- only from the OP2 and complainant encashed the cheque only as partial payment of the legitimate reimbursement but actually complainant paid total Rs.35,907/- but in reality complainant was given Rs.16,000/-.  So, balance amount of Rs.20,261/- has not been disbursed as yet and practically they have not released it showing some unreasonable ground and for which complainant sent notice on 05-03-2013 against that OP2 sent a reply stating that decision in regard of repudiation will be final and binding on TPA and the grievance of the complainant was forwarded to the OP1 for consideration and practically OP1 subsequently regretted stating their inability to pay any further amount which rises a great confusion in the mind of the complainant and in the above situation complainant has prayed for redressal and practically complainant also sent a complaint before IRDA but IRDA did not respond as yet and in the above circumstances present complaint is failed for getting such relief.

          On the other hand OP Insurance Company by filing written statement submitted that the present complaint is not maintainable.  There is no negligence, deficiency on the part of the OP1 and fact remains the claim of the complainant was duly considered and settled and a final settlement amount of Rs.16,000/- was released that was accepted by the complainant and moreover complainant did not apply his mind to the policy condition no.2,3 and 2.4 and Note No.1 as provided thereunder and in fact, as per terms and condition as laid down in Clause 2.3 and 2.4 as well as Note No.1 the OP calculated the total entitlement of the complainant at Rs.16,000/- and that decision is based on reasons and covered by the conditions of the policy so the allegation of the complainant is completely baseless and without any substance.  Moreover, as per provision Clause 4.4.21 and 4.4.22 some other expenses are also not payable and in view of the above circumstances, complainant’s present complaint is not tenable and for which same shall be dismissed.

Decision with Reasons

On proper study of the complaint including the written version and also relying upon the argument as advanced by both the parties and Ld. Lawyers it is found that it is undisputed fact that complainant are holding a mediclaim policy and said policy was purchased as per terms and condition of the policy which are appended in the policy and for the complainant’s own version the complainant is aware of the Clauses as appended with the terms and condition of the policy and no doubt it is admitted that the fact complainant no.2 was admitted for her treatment and was discharged on 28-03-2012 and hospitalization was duly interpreted to the OP2.  In fact complainant no.2 was admitted to the said hospital on 26-08-2012 and after that complainant o doubt submitted a claim for a sum of Rs.35,907/- and it is also fact that OP2 after considering the entire materials and documents including the terms and conditions of the policy released a sum of Rs.16,000/- what have been received  by the complainant but the present case is filed by the complainant for not releasing the balance amount of total claim amount that is Rs.20,261/- so, we shall have to consider whether rejection of claim of the complainant in respect of Rs.20,261/- is justified, legal or not.

          In this regard, we have gathered from the Clause 2.0 to 2.6 including the Note No.1 that treatment cost shall be payable under 2.3 and 2.4 and same shall be at the rate applicable to the room category and in the said Note No.1 it is specifically mentioned that in case insured Opts for a room with rent higher than the entitled category all other expenses as per Clause 2.1 the charges payable under 2.3 and 2/4 shall be limited to the charges applicable to the entitled category.  But from the complaint it is clear that complainant is aware of the fact that room, boarding and nursing expenses as provided by the hospital or nursing home shall not exceed 1percent of the sum insured (without cumulative bonus) per day or actual, whichever is less. 

Considering that fact and also the sum insured of the policy we find that sum insured is Rs.1 lakh so invariably complainant is entitled to Rs.1,000/- per day for room, boarding and nursing home expenses and that has been admitted by the complainant then invariably complainant is aware of the same clause as noted in Note No.1 that the amount payable under Clause 2.3 and 2.4 shall be at the rate applicable to the entitled room category and when that is the fact then it is clear that for treatment or for any other accessory etc. complainant is entitled to the rate as per entitlement of room category and in this regard there is no ambiguity.  Moreover, as per provision of law and also relying upon the ruling reported in 2013(4) CPR 165 NC we are confirmed that parties of mediclaim policy or any contract are directly covered by the policy conditions and no exception or relaxation can be made on the ground of equity.  When that is the fact it can safely be said that the complainant is bound by the clause as mentioned in the said terms and condition of the mediclaim policy and no doubt against the query of the complainant OP sent letter informing the reasons for deducting of Rs.21,600/- and it has been specifically mentioned why a sum of Rs.16,000/- was released and balance Rs.21,600/- has not been released and repudiated and in this regard OP reported under what provision they have deducted Rs.21,600/-.

Practically after giving a thoughtful observation in respect of the present consumer dispute and the claim of the complainant we have gathered that practically OP adopted the legal basis on the terms and condition of the mediclaim policy very maturedly and properly assessed the claim of the complainant and applying the clause 2.0 to 2.6 and Note-1 rightly released Rs.16,000/- out of Rs.35,907/- and in this regard OP also since settlement showed the Annexure 7 and 8 and after considering the Annexure we are confirmed that insurance company properly assessed the same and rightly decided this settlement of claim of the complainant and legally released Rs.16,000/- out of total claim of Rs.35,907/-.

In this respect it is to be mentioned that the Forum cannot go beyond the contract and there is no scope on the part of the Forum to give any further relief to the complainant in view of the mandatory provision of the law that parties are guided and covered by the terms and condition of the policy and Forum has no scope bypass the policy condition under any circumstances, so, considering that principles and proceeding, facts and circumstances we are convinced to hold that OP rightly decided the settlement of the claim and there is no deficiency, negligence on the part of the OP and no way complainant has been deceived by the OP because OP is rightly decided the claim as per terms and condition of the policy and after proper calculation and verification we are also satisfied that the settlement as made by the OP was justified and legal for which we have no power to interfere with such final settlement of the OP and accordingly this complaint bears no merit in the eye of law and fails.

Hence,

Ordered

That the case be and the same is dismissed on contest against the OPs but without any cost.