FINAL ORDER/JUDGEMENT
Smt. SAHANA AHMED BASU, Member,
The case of the Complainant, is that, the father of the Complainant was insured under the OP1 being Policy No. 100700501710008143 and total sum was assured Rs.3,00,000/-. The father of the Complainant was admitted to Medica Super Specialty Hospital Pvt. Ltd on 30/06/2018 and thereafter as per advice of the doctors of the said hospital the father f the Complainant was admitted to Institute of Neuro Science, Kolkata. For the treatment of his father the Complainant had to spent Rs.3,71,000/- . But the OP1 paid Rs.1,23,000/- to the Complainant as full and final settlement. The Complainant wrote a letter date 13/11/2018 to the OP1 requesting him to remit the balance amount of Rs.1,77,000/- out of total sum assured of Rs.3,00,000/-with bonus amount of Rs.57,500/- totaling to Rs.2,34,500/- . In reply the OP1 stated that as per policy they have paid full amount. Lastly the Complainant sent a Legal Notice to the OP1 through his Ld. Counsel requesting him to remit the balance amount of Rs.2,34,500/- to the Complainant but the OPs remained unturned. Finding no other option the Complainant has knocked the door of this Commission.
OP1 has contested the case by filing W.V. contending inter alia that the instant complaint is harassive, malafide, baseless, suppression of facts, false, barred by limitation and misjoinder and non-joinder of the necessary parties. The case of the OP1 is that they have been disbursed the claim reimbursement by the OP2 as per terms and conditions of the Mediclaim Policy being No.100700501710008143. OP2 scrutinized all the documents against the Claim Control No.- NI-6-274563 has been settled for Rs.74,000/- against the amount claimed for Rs.3,23,000/- towards the medical expenses at Medica Super Specialty Hospital, Kolkata for the period from 30/06/2018 to 04/07/2018 and said amount has been credited into the bank account No. 019080200000233 with Yes Bank vide UTR No. KKBK18229554671 dated 17/08/2018 and further an amount of Rs.43,250/- has been credited against the amount Claimed for Rs.2,59,673/-towards medical expenses into the Bank account No. 4712023784 with Kotak Mahindra Bank vide UTR No. 18092800194Z00041 dated 28/09/2018 in full and final settlement. Further it is submitted by the OP1 that Mediclaim Insurance Policy between insurer and insured represents a contract between parties and terms and conditions thereof have to be strictly construed determine extent of liability and insured cannot claim anything which is beyond the terms and conditions of the Mediclaim Insurance Policy. Hence the instant Complaint Petition is liable to be dismissed.
OP2 contested the case by filing Written Version assailing the maintainability of the case and denying all allegations against them. The case of the OP is that the Complainant failed to make out the cause of action and deficiency in service or negligence on the part of the Op2 and even four corner of the Complaint Petition there is no allegation or claim against the OP2. Thereis no agreement between the Op2 and the Complainant or any consideration has been paid to OP2. It is also submitted by the OP2 that they are TPA under OP1 , the claim settling agent and they have already sent the statement of report to OP1.As per statement the insured was 61 years and admitted in Medica Super Speciality Hospital from 30/06/2018 to04/07/2018 for the treatment of intracranial Hemorrhage Craniotomy and Conservative treatment was done. Cashless facility was claimed for the said treatment. Though the sum insured under policy was Rs.3,00,000/- and cumulative bonus of Rs.57,500/- , SL has been restricted to Rs.1,00,000/- as disease on set before enhancement of sum assured as h/o hypertension and Diabetes Mellitus since 2012 which is pre-disposing factor of ailment. Under the above mentioned circumstances the Complaint Petition is liable to be dismissed.
The Complainant and the OP1 have tendered evidence supported by an affidavit. But the OP2 did not adduce any evidence.We have gone thoroughly evidence adduced by the parties including documents on record and gave careful consideration to the arguments advanced by the Ld. Lawyers for the parties.
The admitted fact is that the Complainant and his deceased father were insured under OP1 and there is also no doubt that the father of the Complainant was admitted at Medica Super Specialty Hospital from 30/06/2018 to 04/07/2018 for which the Bill amount raised by the said hospitalwas of Rs.3,49,322/- . Photocopy of the Bill Of Supply issued by the said hospital goes to show that the Complainant paid an amount of Rs.2,43,000/- and an amount of Rs.80,000/- was received from the OP2. On perusal of the record it is found that an amount of Rs.43,250/- was sanctioned by the OP2 as full and final settlement and the said amount credited to the Complainant’s Account vide UTR No:- 18092800194Z00041 dated28/09/2018. The intimation letter sent by the OP2 to the Complainant contains the Deduction Details. Ld. Advocate for the Complainant alleged that sum assuredis Rs.3,00,000/-for each along with Cumulative Bonus of Rs.57,500/-for each in respect of the Mediclaim in question. OPs have wrongfully disbursed Rs.1,23,000/- only, deducting the rest amount i.e.Rs.2,34,500/- (177000+57500).
Ld. Advocates for the OP1 and OP2 argued that said amount was deducted as per Terms and Conditions of the said Policy. Letter dated 28/09/2018 issued by the OP2 goes to show that:
CLAIMED AMOUNT Rs.254673/-, MEMOS ATTACHED Rs.259673/-, PAYABLE AMOUNT Rs.100000/- AS DISEASE ON-SET BEFORE ENHANCE S.I. AS PER CLAUSE NO. 4.1 + CB RS.45000/- (BEYOND RESTRICTED S.I. <BR><BR>DEDUCTION:) Rs.17920/- + 31000/- FOR EXCESS ICU CHG (BEYOD 2% SI….2) +1000/- FOR EXCESS AMOUN AS DOCTOR HEAD (BEING 25% OF SI EXHAUSTED…3) Rs.117723/- + 9673/- FOR EXCESS AMOUNT OF OTHER HEAD BEING 50% OF SI EXHAUSTED <BR><BR>NOTE: RS.8000(NI-6-274563) + Rs.6500 = Rs.14500/- OUT OF RS.36250 FOR ROOM RENT, RS.25000(NI-6-274563) + Rs.47000(NI-6-274563) + RS.25500 = Rs.72500 OUT OF RS.72500 FOR OYHERS HAS BEEN UTILISED UNDER THIS CLAIM.
Neither the Complainant nor the OPs have furnished the Claim Formsubmitted by the Complainant and Terms and Conditions of the said Policy along with their Petitions. Ld. Advocate for the Complainant submitted that the said policy was incepted in the year 2009. Photocopies of the Collection Receipts are annexed by the Complainant in this regard. Ld. Advocate for the OP2 submitted that SI has been restricted to Rs.1,00,000/- as disease on set before enhancement of sum insured as hypertension and Diabetes Mellitus since 2012 which is pre-existing factor of ailment. On scrutiny of the documents on record we noticed that Clinical Summary of the insured issued by the treating hospital reveals in respect of the deceased that:
He is a known diabetic, hypertensive, on regular medication, he had undergone CABG in 2015 on antiplatelet drugs.
We did not find any single scrap of papers which can support the abovementioned submission of the Ld. Advocate for the OP2.Also, as per Collection Receipts furnished by the Complainantin respect of the Mediclaim in dispute was incepted in 2009. If the deceased insured was having Hypertension and Diabetes Mellitus since 2012 as submitted by the OP2 how can it be Pre-Existing Factor of ailment? If so, it is the responsibility on the part of the insurer to get a medical check-up of the insured before enhancement of SI. No such whisper is heard from the four corner of the Petitions of the OPs. Moreover, no documentary evidence has been annexed by the OPs in this regard. Therefore, we are not inclined to consider the aforesaid submission of the OPs.In our considered view, deficiency in service on the part of the OP1 is proved and the gesture of the OP1 is surely falls under unfair trade practice. Therefore, Complainants are entitled to get relief or reliefs.
Based on the above discussion we are of the opinion that the Complaint Petition is allowed on contest against the OP1 in part and dismissed against the OP2 with following directions:
- OP1 is directed to pay Rs.2,31,00/- (173973 + 57500) to the Complainants with simple interest @ 8% within 45 days from the date of passing this order till its realization.
- OP1 is also directed to pay Rs.10,000/- as litigation cost and Rs.20,000/- to the complainants as compensation for causing harassment, mental pain and agony within stipulated period failing which the principal amount shall attract simple interest @12% p.a.
Liberty be given to the complainant to put the order in execution, if the OP transgress to comply the order.
Copy of the Judgment be given to the parties as per rules
