Order No. 15 dt. 20/07/2017
The case of the complainant in brief is that the complainant obtained a policy in the name of Kalpana Das and the policy was valid from 27.8.13 to 22.8.14. During the subsistence of the said policy Kalpana Das became ill and she admitted to S.C. Das Memorial K.D. Cure Nursing Home from 11.10.,12 to 27.11.12. After releasing from the said hospital the complainant submitted the bill of Rs.1,15,516/- but o.p. no.1 accepted the said claim of the complainant and finally issued an offer of Rs.19,971/-, The complainant accepted the same on protest. On the basis of the said fact the complainant filed this case praying for direction upon o.p. insurance company for payment of the claim amount of Rs.1,15,516/- and compensation of Rs.50,000/- and litigation cost of Rs.30,000/-.
The o.ps. contested this case by filing w/vs and denied all the material allegations of the complaint. It was stated by o.p. no.1 that the complainant has no locus standi to approach before this Forum alleging deficiency in service on the part of insurance company. The complainant’s mother-in-law being the senior citizen was provided with a redcarpet insurance policy for the sum insured of Rs.2 lakhs for the period from 27.8.09 to 26.8.09. The insurance policy was issued subject to conditions, clause, warranties, exclusions, etc. attached. As per the said policy the settlement of the claim is inter alia subject to application of co-pay clause of 30% which shall be borne by the policy holder in each and every claim. The insured was admitted to the hospital on 11.10.13 for the treatment of uncontrol DM, intestinal obstruction, UTI. After scrutinizing the claim record and authorized the cashless facility and paid by cheque dt.16.5.14 for Rs.19,971/- under 50% co-pay clause which is payable duly taken into account the nature of illness, treatment, procedure done and also as are reasonably and unnecessarily incurred as stated in the preamble of the policy. In exclusion no.5 of the policy it was clearly stated that each and every claim arising out of all pre existing diseases the insured is liable for 50% of claim amount and 30% in case of all other case which are to be borne by the insured. The o.p. insurance company in the w/v also stated that the complainant will be entitled to get further amount of Rs.23,430/-. On the basis of the said fact o.p. no.1 stated that the claim made by the complainant is a exorbitant one and the same cannot be entertained in respect of the claim of the insured.
In their w/v o.p. no.2 stated that they have been wrongly made a party in this case and it was also stated that Kalpana Das had been admitted in their hospital and discharge certificate was issued by the said hospital. Since there was no liability of the said hospital regarding the claim of the complainant, therefore o.p. no.2 cannot be held liable for any compensation or cost etc. Accordingly, o.p. no.2 prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether Kalpana Das was the holder of the policy at the relevant point of time?
- Whether the amount paid by the insurance company was justified?
- Whether there was any deficiency in service on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the mother in law of the complainant had been in the nursing home during the period from 11.10.12 to 27.11.12 and she was the holder of the mediclaim policy and the policy was issued by o.p. no.1. During the subsistence of the policy the Kalpana Das fell ill and she took admission in the nursing home and after her recovery the complainant submitted medical bills for reimbursement from o.p. no.1 but o.p. no.1 issued cheque of Rs.19,971/- which was much less amount than that of the claim of the complainant and thereby the complainant filed this case praying for direction upon the o.p. no. to release the fund of Rs.1,15,516/- and other reliefs.
Ld. lawyer for the o.p. no.1 argued that as per the terms and conditions of the policy the amount was offered to the complainant and in the insurance policy it has been clearly stated that the insurance under this policy subject to conditions, clause, warranties, exclusions, etc. attached and accordingly a contract of insurance company was entered into between the complainant and o.p. no.1. As per the terms of the said policy the settlement of the claim is inter alia subject to application co-pay clause of 30% which shall be borne by the policy holder in each and every claim. The o.p. no.1 scrutinized the claim record and authorized the cashless facility and paid by cheque no.180690 dt.16.5.14 for Rs.19,971/-. As per exclusion clause no.5 of the policy clearly states that each and every claim arising out of all pre existing diseases the insured is liable for 50% of the claim amount and 30% in case of all other case which are to be borne by the insured. The expenses incurred by the complainant are not payable as per IRDA guidelines viz. service charge, special attendant charge, cost of diaper, bandage, etc. As per exclusion clause no.5 in all pre existing diseases the insured is liable to bear 50% and hence the deduction was made as per clause 5 of the policy Rs.600/- is payable and hence the deduction was made of Rs.750/-. After calculating the necessary deduction it was found that total deduction was made from the bill of rs.70,583/- and the amount paid by the insurance company to the tune of Rs.19,971/- and the insured will be entitled to get the amount of Rs.23,430/-. The insured earlier admitted to the said hospital for fracture left lower tibia and a cheque of Rs.38,335/- was paid under 30% of co-pay clause. There was no deficiency in service or unfair trade practice on the part of o.p. insurance company, there the case is to be dismissed.
Considering the submissions of the respective parties it appears that the complainant is the son in law of the insured. The complainant filed this case praying for the total claim made for the treatment rendered to the insured Kalpana Das. It is also found from the materials on record that the insured was also admitted to the said hospital earlier for the treatment of fracture left lower tibia and she was paid an amount of Rs.38,335/- under 30% of the co-pay clause. The complainant in the self same year again admitted to the said hospital and underwent treatment and after recovery claimed an amount of Rs.1,15,516/-. It is also an admitted fact that as per the terms and conditions of the policy the amount was paid to the complainant. The complainant accepted the amount of Rs.19,971/-. After calculating the amount insurance company clearly stated that on what ground the amount was deducted. After final calculation it was found that the insured will be entitled to get reimbursement of the medical bill to the tune of rs.23,430/-. Accordingly the complainant will be entitled to get the said amount. On perusal of the materials on record as well as evidence adduced by both the parties we do not find any major deficiency in service on the part of o.p. insurance company or there was any unfair trade practice and as per the terms and conditions of the policy the said amount was determined. It is an admitted fact that the insured must bound by the terms and conditions of the policy and as per the said terms and conditions of the policy the said amount was paid and the balance amount the insurance company is agreeable to pay. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.658/2014 is allowed on contest with cost against the o.p. no.1 and dismissed on contest without cost against the o.p. no.2. The o.p. no.1 is directed to pay a sum of Rs.23,430/- (Rupees twenty three thousand four hundred thirty) only to the complainant along with compensation of Rs.5000/- (Rupees five thousand) only for harassment and mental agony and litigation cost of Rs.2000/- (Rupees two thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
