Order-13.
Date-23/02/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
The case of the Complainant in short is that the Complainant is the nominee of Late Arjun Lal Agarwal who died on 13.06.2015. The said Arjun Lal Agarwal obtained a policy under OPs during his life time vide Policy No. 101600/48/14/8500001932 and he paid the premium properly. The sum assured was Rs.3,50,000/- and the cumulative bonus of Rs.53,750/- up to the date of claim. The Petitioner is the wife of Late Arjun Lal Agarwal. The husband of the Petitioner namely Arjun Lal Agarwal since deceased was admitted at Shalby Hospital, Ahmadabad, Gujarat for knee joint replacement on 27th July,2014 and a total sum of Rs.3,04,771/- had been spent for the aforesaid treatment purpose, out of which a sum of Rs.2,82,537/- had been spent for Hospitalization Surgery purpose and Rs.22,234/- had been spent for pre and post hospitalization purpose.
Late Arjun Lal Agarwal lodged a claim for the knee operation amounting to Rs.2,82,537/- dated 11.08.2014 for hospitalization surgery purpose and on 20.11.2014 he also lodged a claim for Rs.22,234/- for pre and post hospitalization purpose. Thus, Arjun Lal Agarwal lodged a total claim of Rs.3,04,771/- before the OPs up to the month of October, 2014. The said Arjun Lal Agarwal died on 13.06.2015 and during his life time he did not get any amount from the OPs in spite of repeated reminders. Lastly, on 17.06.2015 the OPs have paid a sum of Rs.1,76,750/- without details of items or break up of amount paid.
The Petitioner moved before the Hon’ble Ombudsman and Hon’ble Ombudsman also passed an award in favour of the Complainant. The OPs thereafter paid Rs.13,250/- to the petitioner as a nominee on 8th July,2016 without any break up of amount. The OPs have paid an amount of Rs.1,90,000/- without any break up and as such the Complainant is entitled to get a sum of Rs.1,14,771/- from the OPs till the date. It is stated the OPs did not pay to the Complainant the amount of Rs.1,14,771/-. It is alleged that the OPs are deficient in rendering service to the Complainant. Hence this case.
OP No. 1 and 2 have contested the case in filing w.v. contending inter alia that the case is not maintainable in fact and in law. It is stated that insured was unable to provide break up of packages in spite of reminders and hence claim paid for Rs.1,750/- for room rent and rest Rs.1,75,000/- as other expenses i.e. 50 percent of the eligible sum insured i.e. Rs.3,50,000/-. Therefore, the payable amount comes to Rs.1, 76,750/-. It is also stated that further an amount of Rs.13,250/- was paid as Specialists fees under section II, out of Rs. 22,234/- and the balance amount is not payable as the same was already exhausted in the main claim under other head. It is stated that there is no deficiency in service for settling the case. These OPs have prayed for dismissal of the case.
Point for Decision
1) Whether the OPs have been deficient in rendering services to the Complainant?
2) Whether the Complainant is entitled to get the relief as prayed for?
Decision with Reasons
We have scrutinized the documents on record i.e. photocopy of subject Insurance Policy being no.101600/48/14/8500001932, photocopy of supplementary Mediclaim Policy, photocopy of Claim form, photocopy of Bill summary including package break up of total knee replacement, photocopy of Pharmacy Bills, photocopy of collection slips and photocopy of other documents on record.
The instant complaint refers to the Mediclaim of Late Arjun Lal Agarwal. The Mediclaim appears to be in the name of Arjun Lal Agarwal (since deceased) with his wife Smt. Pista Devi Agarwal, the Complainant, both covered under National Mediclaim Policy of the National Insurance Co. Ltd. The Policy No. 101600/48/14/8500001932 was issued under policy period 27.05.2014 to 26.05.2015 covering Mr. Arjun Lal Agarwal, aged 69 years and his wife with a sum insured of Rs.3,50,000/-, the cumulative bonus was Rs.53,750/-. The Complainant alleged that the insured include expenses of Rs.3,04,771/- for knee joint replacement on 27.07.2014 at Shalby Hospitals, Ahmedabad, Gujarat. Out of Rs.3,04,771/-, a sum of Rs.2,82,537/- was spent for Hospitalization surgery and Rs.22,234/- spent for pre and post hospitalization purpose. The Complainant also stated in the petition of complaint in para 6 that OPs paid a sum of Rs.1,76,750/- without details of items or break up of amount so paid. We find that the non submission of details break up and in absence of which the Petitioner Company considered 50 percent of eligible sum insured i.e. Rs.3,50,000/-.
We have also perused Annexure ‘A & A1’ i.e. non TPA Mediclaim Claim processing sheet, Annexure ‘B’ i.e. Eligible amount break up Annexure ‘C’ i.e. letter given to OP by Arjun Lal Agarwal that he did not have break up cost of Rs.1,60,000/- as the same was not provided by the Hospital, Annexure ‘D’ letter dated 21.11.2014 given to Arjun Lal Agarwal by the OPs for providing break up of package total cost for a sum of Rs.1,60,000/- from the respective hospital.
We find that out of total claim of Rs.2,82,537/-, the OP has paid in the following manner.
- Hospital bill for Rs.2,77,447/- of which 1750/- for room rent,
- Rs.1,60,000/- for package knee replacement
- Rs.1,15,697/- for rest expenses.
We find that insured was unable to provide break up of package in spite of reminders and hence claim paid for Rs.1,750/- for room rent and Rs.1,75,000/- for other expenses i.e. 50 percent of the eligible sum insured i.e. 3,50,000/-, therefore, total payable amount comes to Rs.1,76,750/- (Rs.1,750/- + 1,75,000/-). Further as we find Rs.13,250/- was paid as specialists fees under section II of Rs.22,234/- and balance amount is not payable as the same was already exhausted in the main claim under other head. We have also perused Annexure ‘A and A1’ i.e. non TPA Mediclaim Claim processing sheet and Annexure ‘B’ – eligible amount break up.
In view of the discussion as made in earlier paragraphs, we think that there is no deficiency in services for settling the claim, at the rate of 50 percent eligible sum insured i.e. Rs.3,50,000/- for non submission of break up of package in spite of reminders and further Rs.13,250/- was paid as specialists fees under section II out of Rs.22,234/- and balance amount is not payable as the same was already exhausted in the main claim under other head.
We think that the OPs have settled the claim after proper application of mind. So, we think that there is no deficiency in service from the end of the OPs in the matter of repudiation of claim of the Complainant.
In result, the case merits no success.
Hence,
Ordered
That the instant case be and the same is dismissed on contest against the OPs.
No order as to cost.
