Order No. 12 dt. 02/12/2019
The case of the complainant in brief is that the complainant obtained a mediclaim policy from o.p. insurance company and the said policy was renewed in the year 2018 and the policy remained valid during the period from 7.5.18 to 6.5.19. The complainant paid the premium of Rs.12,958/-. During the subsistence of the said policy the complainant’s son became seriously ill and he was taken to emergency unit of Woodland Hospital and on examination the doctor admitted him on 3.11.18 and he was operated on the same day. After discharge of the complainant’s son, the complainant made a claim of Rs.1,48,891/- to o.p. insurance company by producing all the medical papers. After long interval insurance company credited the amount of Rs. 49,301/- in the account of the complainant but the balance amount has not been paid, for which the complainant filed this case praying for direction upon the o.ps. for payment of the balance amount of Rs.99,590/- as well as compensation and litigation cost.
The o.p. nos.1 and 2 contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that as per clause 3.29 the amount claimed by the complainant was not paid, therefore the plea of deficiency in service and non payment of the claim does not arise. The clause 3.29 read with clause 3.23 speaks that reasonable and customary charges means the charges for service or supplies, which the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services taken into account the nature of illness. As per clause 3.29 the insured person suffering from acute appendicitis was treated at Woodland Hospital and falls under PPN Hospital and providing the same service and operation of acute appendicitis. The package charges agreed with CMRI for acute appendicitis is Rs.48,500/-. The above package charges include all charges which include room rent, doctor’s fee, pathological report, medicines, etc. The complainant thus chooses to go for a hospital of his own choice incurring a huge expenditure than customary and reasonable charges within the same geographical area and thus violated the provisions of clause 3.29. The list of PPN hospital have been provided to the complainant along with the policy schedule with terms, conditions and clauses, but in spite of the same the complainant chooses to go for exaggerated expenditure only have to move money from the insurance co. Considering the above TPA has paid Rs.48,500/- being the customary and reasonable charges agreed with CMRI as per item no.23 on the list attached situated within the geographical area of Woodland Hospital plus Rs.801/- towards the expenses incurred for pre and post hospitalization totaling an amount of Rs.49,301/- being the payable amount under the terms, conditions and clauses agreed under the policy issued to the complainant. The insurance company acted as per the terms and conditions of the policy and therefore the claim made by the complainant is fictitious one and as such, o.ps. prayed for dismissal of the case.
In spite of receipt of notice the o.p. no.3 did not contest this case by filing w/v and as such, the case has proceeded ex parte against the o.p. no.3.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy with o.p. insurance company?
- Whether the insured suffered illness for which he was treated at Woodland Hospital?
- Whether the amount paid by insurance company as per the terms and conditions of the policy?
- 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 complainant obtained a mediclaim policy from o.p. insurance company and the said policy was renewed in the year 2018 and the policy remained valid during the period from 7.5.18 to 6.5.19. The complainant paid the premium of Rs.12,958/-. During the subsistence of the said policy the complainant’s son became seriously ill and he was taken to emergency unit of Woodland Hospital and on examination the doctor admitted him on 3.11.18 and he was operated on the same day. After discharge of the complainant’s son, the complainant made a claim of Rs.1,48,891/- to o.p. insurance company by producing all the medical papers. After long interval insurance company credited the amount in the account of the complainant but the balance amount has not been paid, for which the complainant filed this case praying for direction upon the o.ps. for payment of the balance amount of Rs.99,590/- as well as compensation and litigation cost.
Ld. lawyer for the o.p. nos.1 and 2 argued that as per clause 3.29 the amount claimed by the complainant was not paid, therefore the plea of deficiency in service and non payment of the claim does not arise. The clause 3.29 read with clause 3.23 speaks that reasonable and customary charges means the charges for service or supplies, which the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services taken into account the nature of illness. As per clause 3.29 the insured person suffering from acute appendicitis was treated at Woodland Hospital and falls under PPN Hospital and providing the same service and operation of acute appendicitis. The package charges agreed with CMRI for acute appendicitis is Rs.48,500/-. The above package charges include all charges which include room rent, doctor’s fee, pathological report, medicines, etc. The complainant thus chooses to go for a hospital of his own choice incurring a huge expenditure than customary and reasonable charges within the same geographical area and thus violated the provisions of clause 3.29. The list of PPN hospital have been provided to the complainant along with the policy schedule with terms, conditions and clauses, but in spite of the same the complainant chooses to go for exaggerated expenditure only have to move money from the insurance co. Considering the above TPA has paid Rs.48,500/- being the customary and reasonable charges agreed with CMRI as per item no.23 on the list attached situated within the geographical area of Woodland Hospital plus Rs.801/- towards the expenses incurred for pre and post hospitalization totaling an amount of Rs.49,301/- being the payable amount under the terms, conditions and clauses agreed under the policy issued to the complainant. The insurance company acted as per the terms and conditions of the policy and therefore the claim made by the complainant is fictitious one and as such, o.ps. prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant obtained the mediclaim policy from o.p. insurance company and during the subsistence of the said policy the son of the complainant became ill and being insured with insurance company he was treated for acute appendicitis and the complainant’s son was treated at Woodland Hospital. After submission of the documents to insurance company TPA examined the bills. After examination insurance company provided the amount of Rs.49,301/- to the account of the complainant. The complainant has claimed that balance amount of Rs.99,590/- which has not been paid by insurance company for which the complainant had to file this case. The complainant has stated that as per clause 2.1, 2.2 and 2.3 of the mediclaim policy the complainant is entitled to get the reimbursement of the balance amount. On perusal of the terms and conditions of the policy which has been filed by insurance company wherefrom it is evident that insurance company provided the charges to the complainant as per the clause 3.29 read with clause 3.23, but in clause 3.23 of the terms and conditions of the policy PPN has been described which means a network of hospital which have agreed to a cashless package pricing for certain procedure for the insured person. Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates applicable to PPN package pricing. Clause 3.29 has illustrated reasonable and customary charges means the charges for services or supplies which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services taken into account nature of the illness / injury involved. The list of PPN hospital had been provided to the complainant at the time of issuance of the policy. The complainant being aware of the said fact agreed to his own choice went to Woodland Hospital for the treatment of his son, but CMRI Hospital is situated within the geographical area where the Woodland Hospital is situated and the CMRI Hospital is an enlisted hospital within the PPN network. If the complainant would have taken his son to CMRI Hospital the charges would not have been exceeded Rs.49,301/- which has been paid by insurance company. The complainant has also claimed the room rent which the patient was not entitled to enjoy and acordingly, those amonts were deducted. TPA has provided the list of the amount for which it was aproved and the same was also forwarded to the complainant, but the complainant in spite of knowing the details of the accounts approved by TPA which has been accepted by insurance company and insurance company paid the said amoiunt as per clause 3.29 read with clause 3.23 of the terms and condiitons of the policy. On perusal of the materials on record we find that insurance company rightly paid the amount and the claim made by the complainant is an exorbitant one which the insured is not entitled to get as per the terms and conditiions of the policy. In view of the facts and circumstances as stated above, we hold that the case filed by the complainant has got no merit and the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.60/2019 is dismissed on contest against the o.p. nos.1 and 2 and dismissed ex parte against the o.p. no.3 without cost.
