Order-14.
Date-28/02/2017.
Shri Sangita Paul, Member.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant’s case in short is that complainant obtained a family mediclaim policy from O.Ps.-1 and 2 on 17/04/2002. The said policy was issued by the United India Insurance Co. Ltd. for one year and the same is renewed year after year with adequate premium. By this policy complainant, his wife, son and daughter were covered. Complainant’s wife Mrs. Manju Acharya being policy No.0304012815P1001122018 had fallen ill and diagnosed for knee replacement. Accordingly her left knee was replaced at Apollo Chennai Hospital on 26/05/2009. On 03/01/2015 the said insured person developed complication in her left knee and left arm. She had severe pain and limbs swelled. She was admitted to Columbia Asia Hospital on 07/01/2015. Complainant informed the TPA for Cashless facility, but the TPA did attend appropriately to the legitimate claim. Complainant’s wife was discharged on 30/01/2015. Complainant spent Rs.04,41,151/- and submitted the claim for the said expenditure to the O.P. insurance company. The TPA asked for original money receipts for Rs.04,36,943/- of hospital bill. That the O.P. however partially allowed the claim of the complainant and have paid a sum of Rs.38,675/-. The treatment of the insured was continuing and the patient was not at all declared fit and cure, the said mediclaim policy was renewed on its date of renewal on 16/04/2015 and paid premium of Rs.22,764/- for the period of 17/04/2015 to 16/04/2016. Since being deceived from the eligible service of insurance complainant did not renew further. During continuance of the aforesaid treatment the spouse of complainant fell infected with left TKR prosthesis with impending septicemia Hypothyroid sepsis loagntopathy and she was taken to Narayana Super Specialty Hospital on 22/09/2015 where she was admitted till 01/10/2015 and for that complainant spent Rs.01,45,652/-. Complainant wrote to the Regional Manager, UNI, Customer Care Department, Kolkata on 02/02/2016 and also sent an e-mail on 03/02/2016 to reconsider his claim. Complainant again lodged complaint on 06/05/2016 to Insurance Ombudsman. But the O.Ps. did not redress the customer’s claim. Insurance is a contract in between insurer and insured, yet he is deprived of getting the claim amount complainant prays for paying the entire medical expenses of Rs.04,41,151/-, also prays for compensation for harassment and mental agony to the tune of Rs.10,00,000/- with an interest at the rate of18 percent p.a. on the medical expenses borne by complainant for Rs.04,41,151/- and litigation cost.
O.P.-1 and 2 in their written version states that the cause of action arises beyond the territorial jurisdiction of this Ld. Forum. There is no claim lying against TPA and regional office of the insurance company. Complainant has made these parties for invoking jurisdiction of this Ld. Forum O.P. issued the mediclaim policy to complainant in the year 2002 for a sum of Rs.30,000/-. The policy was a continuous policy till 16/04/2008. In 2008 the sum insured was charged Rs.50,000/-, in 2009 Rs.75,000/- , in the year 2011 Rs.2,00,000/-, in 2012 Rs.2,50,000/-, in 2013 and in the year 2015 Rs.4,00,000/-. It can be said that the insured has prior knowledge of disease of his family member but did not disclose the same.
It is admitted fact that as per terms of the policy the insured are entitled to get 70 percent of the sum insured of the treatment of major diseases subject to continuous coverage of 48 months as per clause 4.1 of the policy. As per clause 5.11 it is stated that ‘liability of the company shall be only to the extent of the sum insured under the policy in force at the time of when it was contracted or suffered’. At the time of operation the sum insured was Rs.75,000/- only. Complainant as per policy condition is entitled to get 70 percent of the sum insured i.e. Rs.1,75,000/-. Since the insurer i.e. United india Insurance Co. Ltd. already paid excess money in their earlier claim complainant is not entitled to get extra money from the insurance company.
The TPA erroneoly disbursed Rs.1,75,000/-. Considering that the policy of insured was Rs.2,00,000/-. The TPA ought to have considered that as per policy condition the complainant’s claim ought to be settled maximum at Rs.75,000/- Rs.2,00,000/- does not come within the terms of the policy. The premium for the period 17/04/2014 to 16/04/2015 the policy was enhanced to Rs.3,00,000/-. The insured was at treatment of Pyogenic arthritis of left knee and claimed Rs.4,41,151/- illegally and arbitrarily.
Decision with Reasons
Upon travelling over the documents on record i.e. complaint petition, written version, evidence-in-chief and other documents it is revealed that complainant took mediclaim policy from United India Insurance Co. Ltd. After being treated at Apollo Chennai Hospital on 26/05/2009, for knee replacement her complication continued. She had problem in left knee and left arm. Complainant submitted the claim and the TPA disbursed Rs.1,75,000/-. Considering
the policy of the insured as Rs.2,00,000/- TPA erroneously disbursed Rs.1,75,000/-. In the year 2009 the sum insured of complainant was Rs.75,000/-. So he is not entitled to Rs.1,75,000/-. As per written version of O.Ps.-1 and 2, TPA has disbursed excess amount but they did not inform complainant of disbursing the excess amount. Again complainant developed problem and was admitted to Columbia Asia Hospital. She was admitted on 07/01/2015 and has discharged on 30/01/2015. Complainant incurred an expense of Rs.4,36,943/-. He again submitted the claim for expenditure. In the year 2015 the sum assured of complainant was Rs.4,00,000/-. The O.P. however partially allowed the claim and disbursed Rs.38,675/-. O.Ps. contention is that in the first operation they have disbursed the amount which the complainant was not entitled to get. But O.Ps. can’t adjust this claim with the earlier claim. The first operation was held in the year 2009 and the second operation was conducted in the year 2015. The sum assured was also increased from Rs.75,000/- (2009) to Rs.4,00,000/- (2015). Again she was admitted to Narayana Super Specialty Hospital but did not avail of cashless facility but in the year the sum insured was Rs.4,00,000/-. So he is entitled to get more. Complainant wanted claim of Rs.4,36,943/- only. He got Rs.38,615/- only. In any operation complainant is entitled to get 70 percent of the total expenditure of sum insured subject to continuous coverage of 48 months as clause 4.1 of the policy. So complainant is to get an amount exceeding Rs.38,615/-. O.Ps. activities amount to deficiency in service and unfair trade practice. Hence complainant is entitled to get compensation.
In result, the case succeeds.
Hence,
Ordered
That the case be and the same is allowed on contest against the O.Ps.-1 and ex-parte against O.P.-3.
O.Ps. are jointly and severally directed to reimburse the amount of Rs.2,40,000/- within one month from the date of this order.
The O.Ps. are jointly and severally directed to pay an amount of Rs.10,000/- as compensation for causing harassment and mental agony to complainant along with litigation cost of Rs.10,000/- within the said stipulated period.
Failure to comply with the order will entitle the complainant to put the order into execution u/s.25 read with Section 27 of the C.P. Act and in that case OP shall be liable to pay penal damage at the rate ofRs.5,000/- per month to be paid to this Forum till full and final satisfaction of the decree.
