The complainant’s case is that complainant made Health Policy of all his family members with the help of Op no.4 under OP no.3. The wife of the complainant was treated in Bansal Nursing Home Centre on 26.6.2013 and surgery was made on 27.6.2013 and discharged on 2.7.2013. The complainant filed claim before Op no.1 and 3 who paid Rs.17,693/- where actual claim was Rs.52,725/-. It is alleges that Op no.1 illegally deducted the claim amount from the actual claim Rs.52,725/- . So the conduct of the oP no.1 is against the law. The complainant
requested the oP no.1 and 3 for full payment of Rs.52,725/-. But the oP no.1 and 3 did not grant the prayer of complainant . Hence this case.
Op no.3 has appeared and filed WV denying inter alia all the material allegations . It is the case of the oP no.3 is that Opposite party no. 1 and 3 already disbursed the claim amount in favour of the complainant amounting to Rs.17,693/- as per policy condition, as per calculated amount of op no.1 and 3. As calculated amount of Rs.17,693/- have been paid by the oP no.1 and 3 so case should be dismissed.
Op no.3 has filed Written Version. The case of Op no.3 is that , the Op no.1 and 3 already paid Rs.17,693/- as per Policy condition. Op no.3 also stated the other claim amount Rs.25,000/- , Rs.1000/- by other bill is not correct and those documents were not under the bill of Nursing Home which is the condition of the Policy and those are manufacture to establish the claim of Rs.52,725/-. As the calculated amount of Rs.17,693/- has been paid , so the complainant is not entitled any increased amount. As such, Op no.1 rightly repudiated the claim of the petitioner as per terms and conditions of Mediclaim policy. So , deficiency of service does not arise at all.
POINTS FOR DECISION
- Whether the complainant is a consumer ?
- Whether there is any deficiency of service on the part of the oPs?
- Whether the complainant is entitled to get relief as prayed for ?
DECISION WITH REASONS :
All the points are taken up together for the sake of convenience and brevity of discussion.
It is admitted position that complainant was treated in the Op hospital of Op no.1. It is also admitted that the complainant’s wife and other members had Health policy. It is alleges that complainant’s claim Rs.52,725/-. Op no.1 and 3 paid Rs.17,693/- as per calculation made by Op no.1 and Op no.3. There is no material adduced by the complainant to show that , their calculated amount in the Bansal Nursing Home centre is Rs.52,725/-. On the other hand, Op no.1 and 3 stated and calculated the cost at Rs.17,693/-. In absence of any cogent reason shown by the complainant we are unable to reject the contentions of Op no.1 and 3 that they paid the amount Rs.17,693/- as was calculated by Op no.1 and 3 is wrong i.e. they paid the correct amount as per calculation of cost borne by the complainant for treatment. Thus, we are of the opinion that the case fails. Hence –
Ordered
That the C.C.no. 166 of 2014 be and the same is dismissed on contest but without cost.
Let a copy of this order be made over to the parties free of cost.
