| ORDER | DATE OF FILING : 26.09.2014. DATE OF S/R : 23.07.2014. DATE OF FINAL ORDER : 06.10.2015. Asit Baran Chowdhury, opposite ‘Health for All’, Kantalia, Makardah, Howrah, PIN 711409. ………………………………………………………… COMPLAINANT. 1. The Manager, The New India Assurance Co. Ltd., Howrah District Branch, P 18, Dobson Lane ( 2nd Floor ), Howrah 711101. 2. The Claim Manager, M/s. Medicare TPA Services (I) Pvt. Ltd., 6, Bishop Lefroy Road, Kolakata 700020. …………………………………………OPPOSITE PARTIES. P R E S E N T Hon’ble President : Shri B. D. Nanda, M.A. ( double ), L.L.M., WBHJS. Hon’ble Member : Smt. Jhumki Saha. Hon’ble Member : Shri A.K. Pathak. F I N A L O R D E R - This is an application U/S 12 of the C.P. Act, 1986 filed by the petitioner, Asit Baran Chowdhury, against the o.ps., the New India Assurance Company Ltd. and M/s. Medicare TPA Services (I) Pvt. Ltd., praying for direction upon the o.ps. to pay him Rs. 80,000/- as his claim.
- The case of the petitioner is that he had media claim policy for himself and his wife, Dolly Chowdhury, who had Carpal Tunnel Surgery on her right hand on 07.06.2013. Later on the same C.T.S. on right hand was done on 13.05.2014 in the same PPN Hospital. In the first case out of total expenditure amounting to Rs. 33,533/- the TPA paid Rs. 27,000/- during the right hand operation but paid only Rs. 15,000/- during the second operation though the total expenditure was Rs. 34,035/-. The insurance coverage was Rs. 1 lakh. He got puzzled with the health policy and prayed for reimbursement before the TPA who only paid Rs. 15,000/- and so he filed this case.
- The o.p. no.1, New India Assurance Co. Ltd., contested the case by filing a written version denying the allegations made against them and submitted that the petitioner took the medi claim policy in 2007 which was valid during the period 08.7.2013 to 07.07.2014 covering the risk of hospital expenditure for himself, his wife and son for a sum of Rs. 1 lakh subject to terms, conditions, limitations and exceptions thereof. The o.p. no. 1 admitted the treatment of wife of petitioner of her C.T.S. and discharged on 07.06.2013. They further submitted that as per Regulation of I.R.D.A. the settlement of claim arising out of medi claim policy for the government insurance companies are now done by the independent licensed organization being Third Party Administrators ( TPAs) who act as interface of Government. In the instant case the T PA settled the matter and finally paid Rs. 15,000/- as maximum permissible limit of PPN within the purview of the policy. In the instant case Rs. 15,000/- was paid by the TPA and Rs. 19,035/- paid by the petitioner because the insured sum was Rs. 1 lakh for which Rs. 15,000/- would be allowed as could be noticed from the policy and the TPA in their letter dated 02.06.2014 clarified the same. So the remaining expenses of Rs. 19,035/- paid by the petitioner cannot be entertained neither by the insurance company nor by the TPA and the claim be dismissed. 4. The o.p. no. 2 being the Claim Manager, M/s. Medicare TPA Services (I) Pvt. Ltd. , though served with notice did not appear in the case and filed any objection and thus the case is heard ex parte against the o.p. no. 2.
5. Upon pleadings of the parties the following points arose for determination : - Is the case maintainable in its present form ?
- Whether the petitioner has any cause of action to file the case ?
- Whether there is any deficiency in service on the part of the O.Ps.?
- Whether the complainant is entitled to get any relief as prayed for ?
DECISION WITH REASONS : - All the issues are taken up together for the sake of convenience and brevity for discussion and to skip of reiteration. This Forum heard the ld. counsels of both parties who filed written argument and also verbally submitted and on scrutiny of the claim petition as well as the written version of the parties and the oral and documentary evidences, this Forum finds that the instant case the petitioner prayed for a claim amount of Rs. 34,035/- including Rs. 15,000/- already paid to him as per PPN Rate. It is further submitted on behalf of the petitioner that his wife, Doly Chowdhury, had Carpal Tunnel Surgery on right hand on 07.06.2013 and out of the total expenses of Rs. 33,533/- the TPA paid him Rs. 27,000/-. The C.T.S. of left hand for said Dolly Chowdhury was completed on 13.5.2014 and the total expenses were Rs. 34,035/- but the TPA though paid Rs. 27,000/- for the first operation in 2013 and only paid Rs. 15,000/- for the second operation in 2014 and the rest Rs. 19,035/- was paid by the petitioner for which he filed this case as the TPA as well as insurance company did not pay the said amount.
- It is noticed from the policy document that the petitioner had this medi claim policy since 2007 and during the period when the second CTS on left hand done then the policy was a valid one as valid from 08.07.2013 to 07.07.2014 and the operation took place on 13.05.2014 and the o.ps. also did not object to the same. The o.ps. submitted that the petitioner have medi claim policy for himself, his wife and his son amounting to Rs. 1 lakh each for the insured and as per the Preferred Provider Network System the TPA i.e., Third Party Administrators paid a sum of Rs. 15,000/- as per the permissible limit in this case and the petitioner accepted the same and now he cannot make any further claim because the claim was settled keeping in mind the terms, conditions and limitations of the policy and after full and final settlement of the claim the petitioner cannot make further claim. On scrutiny of the documents specially the claim form submitted by the petitioner, Asit Baran Chowdhury on 24.05.2014 it is noticed that he consented and authorized the o.p. insurance company and the TPA to seek medical information from the hospital and also he authorized the TPA to make payment of the claim admissible as per terms, conditions and limitations of the policy on his behalf for full and final settlement of the hospital bill and also authorized the TPA to receive the payment from the insurance company after such settlement of the claim. Now the petitioner cannot claim further because the petitioner once having accepted the insurance amount in full and final settlement of his claim now cannot be allowed to go back once the document has been signed by him.
- Our National Commission in the case of Pulkit General Store vs. National Insurance Company Ltd. categorically opined that the petitioner in the said case accepted a sum of Rs. 5,561/- and voluntarily singed the discharge voucher in full and final settlement of the claim and so the National Commission did not allow them to go back to claim further and finding no merit dismissed the revision.
- Our Apex Court also in the case United India Insurance vs. Ajmir Singh Collon and General Mills and others 1999 CPJ Vol. II page 10 ( Supreme Court ) opined in the same tune that the petitioner once accepted the amount in full and final settlement of the claim then he cannot be allowed to go back further.
- In the instant also this Forum finds that the petitioner has already accepted the claim which was settled in his favour by the TPA and the matter was already dismissed of and now it cannot be reopened.
In view of above discussion and finings this Forum finds that the petitioner miserably failed to bring home the allegation made against the o.ps. The claim case fails. The court fee paid is correct. Hence, O R D E R E D That the C. C. Case No. 343 of 2014 ( HDF 343 of 2014 ) be and the same is dismissed on contest against the O.P. no. 1 and ex parte against the o.p. no. 2 without costs. Supply the copies of the order to the parties, free of costs. DICTATED & CORRECTED BY ME. ( B. D. Nanda ) President, C.D.R.F., Howrah. | |
