FINAL ORDER/JUDGEMENT
SHRI ASHOKE KUMAR GANGULY, MEMBER.
This is a complaint case u/s 12 of the CP Act, 1986. The brief facts of the case is that the Complainants Sumayya Jahan had a Medi classic Insurance Policy of Sum assured of Rs.1,50,000/- bearing no. P/190000/01/2018/013882 with the OP Insurance Company for the period from 13.01.2018 to 12.01.2019. For treatment of Gall Bladder the complainant got admitted in Fortis Hospital on 22.09.2018 and discharged on 28.09.2018 after necessary operation. The total expense was Rs. 1,49,596/- out of which Rs.98,970/- and Rs.4,780/- were paid. Rs.46,146/- was not paid by the OP. The complainant filed the instant case for reimbursement of the balance amount of Rs.46, 146/ along with other charges of Rs.16,000/- as mentioned in the petition.
The OP has contested the case by filing WV contending interalia that the complaint petition is motivated, misconceived and illegal one. They have admitted that the complainant had the above mentioned policy enforced for the period from 13.01.2018 to 12.01.2019 and benefits etc. are subject to terms and conditions of the policy. The OP has stated that the complainant got admitted in Fortis Hospital, E.M.Bye Pass, Kolkata on 22.09.2018 for Gall Bladder operation and discharged on 28.09.2018. The diagnosis was Acute Calculous Cholecystitis. Rs.20,000/- was approved on 23.009.2018 for Cashless treatment and thereafter the OP finally admitted 98,970/-on 28.09.2018.and settled the payment with the Hospital on 08.11.2018 through NEFT. Subsequently the complainant submitted the final bill of Rs.1,38,513/- to the OP for the above referred treatment. Against that the OP further approved Rs.4,480/- and settled the same on 12.11.2018 through NEFT. As such against the total claim of Rs.1,38,513/- the OP has paid Rs.1,03,450/- ( Rs.98,970/- + Rs.4480/-) which is the maximum amount payable under the policy. The deduction amount is Rs.35,133/- . The said deduction is according to the terms and conditions of the policy. As per preamble of the policy the expenses relating to Hospitalisation will be considered in proportion to the eligible room rent stated in the policy. Since the claim has been settled as per the terms and conditions of the policy the consumer complaint is liable to be dismissed with costs.
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Points for Determination
On the pleading of parties the following points have necessarily come up for determination.
- Whether the OP has got deficiency in service.
- Whether the OP is indulging unfair trade practice.
- Whether the Complainant is entitled for the relief/reliefs as prayed for.
Decision with Reasons
Points Nos. 1 to 3 :-
All the points are taken up together for the sake of convenience and brevity in discussion.
Complainant and the OP have tendered their Evidence on Affidavit. Both have replied to the questionnaire set forth by their adversaries. OP has submitted their BNA also.
We have travelled over all the documents placed on record.
Facts remain that Gall Bladder operation took place during the period when the subject policy was in force which is admitted fact. In view of that the claim was processed and settled by the OP as per the terms and conditions of the policy. The amount claimed by the complainant is Rs.1,49,596/- stated in his complaint petition but the said claimed amount is not supported by proper documents. Only xerox copies of some bills & papers have been furnished with the complaint petition. Though the said documents are not properly submitted as per law but on bare perusal of those papers it is observed that the total payable amount was Rs.1,11,524/-. But on examining the annexure of the OP it is observed that the claim amount was Rs.1,38,513/-. Against the said claim amount of Rs.1,38,513/- the OP has settled the claim by paying Rs.1,03,450/- which has been admitted by the complainant also. The balance amount of Rs.35063/- has not been paid. The OP in their W/V has clearly mentioned that “ as per preamble of the policy the expenses relating to hospitalization will be considered in proportion to the eligible room rent stated in the policy. The OP in their W/V has categorically mentioned item wise deduction against the claim amount .They have furnished in tabular form, the claim amount, non payable amount and approved amount. As per the said break up the claim has been settled. Against the said submission of the OP we do not find any counter submission made by the complainant with proper documents.
. Moreover, on the face of the policy it is clearly written that expenses relating to the hospitalization will be in proportion to the room rent stated in the policy
Considering the facts and circumstances of the case and the documents placed on record we are of the considered view that the complainant has not been able to establish his case against the OP.
Thus all the points are answered accordingly.
In the result, the Complaint fails.
Hence,
Ordered
That the Complaint case be and the same is dismissed on contest against the OP without any cost.
