Smt. Sahana Ahmed Basu, Member.
This is an application u/s.12 of the C.P. Act, 1986.
The case of the complainant in brief is that the complainant had purchased a Mediclaim policy bearing No.P/191113/01/2017/005255 duly issued by O.P.-1 for himself and his wife for the period from 17/12/2017 to 16/12/2018 having the insured value of Rs.2,00,000/- upon payment of premium of Rs.13,975/-. The complainant’s wife was admitted in Belle Vue Clinic on 26/08/2017 and had to undergo surgery on 27/08/2017 and discharged therefrom on 28/08/2017. The complainant had lodged the claim withO.P.-1 for reimbursement of the treatment and medicine etc. for the sum of Rs.1,17,422/- i.e. Rs.1,16,157/- for hospitalization and Rs,1,265/- for post hospitalization. All the medical bills in original were submitted on 09/10/2017. The O.Ps. paid a sum of Rs.56,759/- directly to the account of the complainant through RTGS after making deduction of Rs.58,822/-. Complainant had sent a legal notice toO.Ps. through his Ld. Advocate under speed post with A/D dated 02/01/2018 with a request to pay the balance amount of Rs.58,822/- within 7 days from the date of receipt of the notice. But the O.Ps. remained unturned. Finding no other way, the complainant approached to the Forum for getting relief.
O.Ps. contested the case by filing W.V. The case of the O.Ps. is that they issued “Family Health Optima Insurance Policy” covering the complainant and his wife for a sum insured of Rs.2,00,000/-. The insurance was renewed for the period from 17/12/2017 to 16/12/2018. In the said insurance it has clearly stated that “the insurance under this policy is subject to conditions, clause, warranties and exclusions etc. attached” and accordingly a contract of insurance entered into by and between the complainant and the O.Ps. The insured patient was hospitalized on 26/08/2017 in Belle Vue Clinic, Kolkata for the treatment and submitted a claim for reimbursement of medical expenses. On receipt of the same Rs.56,759/- was settled vide NEFT transaction No.189825 dated 12/12/2017. The said amount had been settled to the insured as per terms and conditions of the policy against the total claimed amount of Rs.1,17,422/-. O.Ps. submitted that deductions were made in accordance with terms, conditions, exclusions of the policy and guidelines of IRDA and the complainant accepted the same without any protest. Therefore, they prayed before the Forum to dismiss the instant complaint with exemplary cost.
On pleadings of the parties following points necessarily came up for determination –
- Whether the O.Ps. have been deficient in rendering services to the complainant ?
- Whether the have indulged in unfair trade practice ?
- Whether the complainant is entitled to get any relief or reliefs as prayed for ?
Decision with Reasons
Points No.-1 to 3.
All the points are taken up together for the sake of convenience and brevity in discussion.
Both the parties have tendered evidence supported by an affidavit and they have also given reply against the questionnaire set forth by their adversaries. Both the parties have also filed BNAs.
Admittedly the complainant obtained a mediclaim policy from the O.Ps. for the period from 17/12/2017 to 16/12/2018 for a sum assured of Rs.2,00,000/- for him and his wife. It is also true that the complainant’s wife admitted in Belle Vue Clinic for surgery and the complainant submitted a claim before O.Ps. for reimbursement of the cost of the medical treatment for Rs.1,17,422/-. Undisputedly the O.Ps. repudiate the claim and settled the claim to the tune of Rs.56,759/- and transferred the said amount to the bank account of the complainant through NEFT.
On perusal of the documents filed by the parties, we find that as per terms and conditions of the policy the complainant was to get up to Rs.2lacs of the sum insured. The complainant’s wife was admitted in a room which rent was Rs.7,900/- per day. The O.Ps. deductedRs.3,900/- per day which is not unlawful. They deducted the other expenses i.e. the reasonable necessarily expenses, investigations and diagnostics relating to the hospitalization considered in proportion to the room rent stated in the policy. We find no wrong in this. That such deduction is as per terms and conditions of the policy.
They deducted Rs.11,156/- as per IRDA Guidelines and other excluded expenses which are not payable, the charges towards gauge, blade, bactigras, skin, prep, musk, cap, wrap sheet, glove, drope, trolley cover, towel, gown, water crepe bandage, mop, mask, diaper, which are not acceptable whereas the total expenditure is Rs.5,884/-. We found they deducted excess amount of Rs.5,272/-. As per IRDA guidelines and other expenses, the charges towards RMO, extra couch, tea, GST, SGST, diathermy, c-arm, omnipaque, are also not payable. We find from the documents furnished by the complainant that the charges of the abovementioned are Rs.11,740/-. ButO.Ps. deductedRs.12,440/- which is more than theactual expenditure.
It is not mentioned in the clause-1.0 of the policy that the professional fees(i.e. surgeon, anesthetist, consultation charges etc.) is related to the hospitalization considered in proportion to the room rent. On the contrary, it is mentioned in the clause-1.0(B) of the policy that the insured is liable to get surgeon, anesthetist, medical practitioner, consultant, specialist fees. Therefore, deduction of Rs.20,240/- from Rs.43,000/- as the professional fees is not justified. Clause-1.0(C) of the policy goes to show that operation theatre charges is under coverage of the said policy. So the deduction of Rs.2,049/- from Rs.4,150/- for OT charges as per final bill furnished by the complainant of the Belle Vue Clinic is not legitimate.
O.Ps. submitted that they had acted within the parameters of the policy conditions and the claimant insured has no authority to challenge such terms and conditions of the policy before the Forum. But we find that the O.Ps. themselves violated their terms and conditions mentioned in the policy. They have mentioned the observation by the Hon’ble Supreme Court as well as NCDRC that the Insurance Policy is a contract and terms and conditions in contract are strictly and equally binding upon both the insurer and insured and no party under such contract can challenge the terms and conditions of the same. On perusal of the documents furnished by the parties we find that the O.Ps. violated the terms and conditions of the policy.
O.Ps. have argued that the complainant accepted the amount paid by the O.Ps. We find no logic in this submission. Because O.Ps. paid the amount through NEFT where the complainant had no opportunity to raise any objection against such settlement.
In view of the above, we are of the opinion that the O.Ps. had deficiency in service and unfair trade practice to settle the claim of the complainant. Therefore, the complainant is entitled to the amount of Rs.32,398/- which was deducted unlawfully. Thus, all the points answered in the affirmative.
As such, the case succeeds in part.
Hence,
Ordered
That the case be and the same is allowed on contest in part against the O.Ps. with cost of Rs.5,000/-.
O.Ps. are directed to release Rs.32,398/- in favour of the complainant within one month from the date of this order along with litigation cost.
O.Ps. are also directed to payRs.10,000/- as compensation for causing harassment, mental pain and agony within the afore said stipulated period.
Liberty be given to the complainant to put the order into execution,if the OPs transgress to comply the order.
