Sri Shyamal Gupta, Member

Challenge under this Appeal is the Order dated 29-09-2015, passed by the Ld. District Forum, Siliguri in CC No. 99/2013, whereby the complaint case has been allowed. 

Brief facts of the complaint case are that the Complainant got admitted at the OP No. 2 hospital for treatment of her ailment.  In this connection, the OP No. 2 raised a bill amounting to Rs. 3,85,402/-, out of which an amount of Rs. 2,31,630/- and another sum of Rs. 1,53,772/- were payable by the OP No. 1 and the Complainant, respectively.  Being compelled to incur such huge expenditure from her own coffers, the Complainant took up the matter with the OP Insurer and after repeated follow up, the OP No. 1 informed her that it paid a sum of Rs. 2,80,000/- against the subject policy to the OP No. 2.  Thus, it is alleged that the OP No. 2 realized an excess amount of Rs. 48,370/- from her.  Although the Complainant urged the OPs to return the excess amount several times, they did not pay any heed to her prayer; hence, the complaint. 

Counter case of the OP No. 1 is that it obtained initial cashless approval from the TPA of the OP No. 1 Insurance Company for a sum of Rs. 2,25,000/- subject to terms, conditions, exclusions and limitation of health coverage plan of the patient.  Thereafter, the concerned TPA sent another approval for a sum of Rs. 55,000/-.  Thus, in total Rs. 2,80,000/- was approved by the OP Insurer through its TPA.  After completion of treatment of the patient, this OP submitted net bill amounting to Rs. 3,85,402/-; out of which patient’s share was figured out as Rs. 1,53,772/- and that of the TPA at Rs. 2,31,630/-.  It is further submitted that, the aforesaid sum of Rs. 2,31,630/- has already been paid to the OP No. 2.  It denied that the Complainant made any excess payment to the OP No. 2 and therefore, question of returning the alleged sum does not arise at all.

The OP No. 2 too contested the case by filing WV, wherein it echoed the version of the OP No. 1 and denied any deficiency in service on its part, as alleged.

Decision with reasons

Be it mentioned here that although the Respondent No. 1 initially contested the case, at the time of hearing, she remained absent.  Therefore, we heard the submission made on behalf of the Appellant and Respondent No. 2.

It is quite apparent that, out of sheer misunderstanding the instant complaint case was filed.  No such document is forthcoming before us that the Respondent No. 2 remitted a sum of Rs. 2,80,000/- to the Appellant; it merely approved this sum through its TPA.  It is common prudence that approving a certain amount and pay the same are altogether different things; both cannot be equated under any circumstances.

The Appellant as well as the Respondent No. 2 made it crystal clear through their respective WVs that the approved amount was payable subject to terms and conditions laid down under the policy.  For some obscure reasons, such averment did not cut ice with the Ld. District Forum. 

On a reference to the petition of complaint and other documents, we do not come across any such evidence to the effect that while figuring out the respective shares of the Respondents in respect of the hospital bill, any error crept in.  It was incumbent on the part of the Respondent No. 1 to prove her case.  Unfortunately, she has miserably failed to discharge this onus.  We are afraid, therefore, that the Respondent No. 1 deserves no relief. 

Accordingly, the Appeal succeeds.

Hence,

O R D E R E D

The Appeal stands allowed ex parte against the Respondent No. 1.  The impugned order is hereby set aside.