Per Hon’ble Mr.Narendra Kawde, Member
Heard Mrs.Kalpana Trivedi-Advocate for the appellant and Ms.Rashmi Manne-Advocate for the respondent.
This appeal is directed as against the order dated 03/06/1999 passed in consumer complaint no.26/1997, (Smt.Punamia Santoshdevi v/s. The Divisional Manager, New India Assurance Co.Ltd.,) by District Consumer Disputes Redressal Forum, Mumbai Suburban. District Forum while allowing the consumer complaint directed appellant/opponent/Insurance Company (herein after referred to as ‘Insurance Company’) to pay an amount of `87,549.50 together with interest @ 18% p.a. w.e.f.17/06/1997 till realization and `5,000/- as compensation in settlement of mediclaim under the ‘hospitalization and domiciliary hospitalization benefit policy’ issued by the appellant/Insurance Company to the respondent/ complainant.
2. Aggrieved and dissatisfied with the impugned order Insurance Company has filed this appeal on the ground that the entire claim of `87,549.50 was not admissible on account of operation and hospitalization charges and, therefore, insurance claim was repudiated. However, stated that an amount of `40,870/- is payable under the insurance policy conditions appearing in table of benefits in the Category -I. There is no other ground pleaded in the appeal memo.
3. Undisputed facts are that the Insurance Company issued Medicalim (Hospitalisation and Domiciliary Hospitalisation) policy. During the validity period of the policy, respondent /complainant underwent cardiac surgery which required hospitalization for about 20 days effective from 03/04/1996 to 22/04/1996. For the operation charges together with hospitalization charges the bill was issued by the hospital authorities to the tune of `85,367.60. Thereafter the insurance claim was preferred on the basis of hospital bill by the respondent/ complainant which came to be repudiated on the ground that the claim falls under the exclusion clause of policy viz.2.1.14.
4. During the course of hearing Ld.Advocate for the Insurance Company conceded that amount admissible under Table of Benefits which is a policy condition in the policy document is payable and such an amount according to her works out to `49,670/- and not entire claim of `85,367.60ps. It was submitted by Ld.Advocate for the respondent/complainant that the amount as per hospital bill issued by P.D.Hinduja Hospital Trust amounting to `85,367.60ps. falls very much within the scope of terms and conditions of the policy and it is entirely admissible. However, it is erroneously repudiated by the Insurance Company.
5. Hospital bills and the terms and conditions are admitted documents, only the quantum is in dispute. There is no dispute as to hospitalization and operation of the respondent/complainant during the hospitalization period. It is only the quantum required to be reimbursed in view of Caps for each and every item described in the policy is in dispute. We have gone through the hospital bills carefully. As per the Table of benefits payable under the policy, room charges including ICU units there is aggregate limit of `33,000/- whereas such a bill on account of these two items is negligible which comes to `3,600/- and `2,600/-. There shall be no difficulty in allowing this expenditure as admissible. In the item (B) of the policy table which provides fees of the expert doctors and actual operation together with medicine and drug charges including Anesthesia, blood, oxygen which forms part of operation management provides limit of `22,000/- and `28,000/- respectively. Under this caption also the total bill issued by the hospital amounts to `39,558/-. This bill is less than what is admissible under the policy. All other charges are very much recorded as part of operation management including medical practitioners visit fees, examination of blood, radiology, etc. Therefore, these bills cannot be excluded from the payment of admissible amount under the Table of benefits listed in the policy. In view of facts and circumstances, there is no merit in the contention of the Insurance Company as all hospital bills on careful scrutiny relates only to the items shown in the Table of benefits payable under the policy except surgical and other items limiting to `28,000/-. Impugned order is required to be modified and substituted by allowing appeal partly. We hold accordingly and pass the following order:-
ORDER
Appeal is partly allowed.
Impugned order of the District Forum is modified and substituted as under:-
Appellant/Opponent/Insurance Company is directed to pay a sum of `76,069/- to the respondent /complainant @ 18% at simple interest w.e.f.17/06/1997 till realization of the claim and pay `5,000/- as compensation and cost to the respondent/complainant within two months from receipt of copy of the order.
Rest of the order remains unchanged.
Pronounced on 5th September, 2012.
