PER SHRI. S.M. RATNAKAR – HON’BLE  PRESIDENT

 1)        The present compliant is filed under Sec.12 of the Consumer Protection Act, 1986, consisting the brief facts as under –

The Complainant having Mediclaim Policy for the period from 09/07/2009 to 08/07/2010 covering all his family members including his spouse and three childrens.  The said policy being renewed having cumulative bonus approved thereon from time to time.  The sum insured under the policy was Rs.2 Lac + 2 Lac for himself and his spouse + Rs.50,000/- for his respective children.  The copy of it is marked as Exh.‘C-1’

2)        It is alleged that the Complainant’s wife Mrs. Alka Pramod Lath (Second Insured) was required some medical treatment for Dengue fever with Hypothyroidism, therefore, she was admitted in Bombay Hospital at Mumbai on 06/10/09 for the said medical treatment.  The Complainant had incurred an amount of Rs.59,184/-. As there was an insurance coverage under the Mediclaim Policy, the Complainant submitted claim form alongwith covering letter dtd.23/11/09 detailing therein the treatment and amount spend on the treatment.  The copies of which were submitted to the Opposite Party No.1 are marked as Exh.‘C-2’ colly.  It is submitted that thereafter, the Complainant received the claim query from the Opposite Party No.2 vide its letter dtd.07/12/09 which is marked as Exh.‘C-3’.  The Complainant received the said letter 22/12/09 as he was away from the station.  So he replied the said query vide letter dtd.08/01/2010 and explained as to under what circumstances the admission of his wife was less than 24 hrs.  The Complainant also requested to take lenient view and settle the claim.  The copy of the said letter is marked at Exh.‘C-4’.   

 3)        According to the Complainant, thereafter, he received a letter from Opposite Party No.2 dtd.19/01/2010, thereby repudiating the claim as non tenable under clause 3.4 of the insurance policy, as the patient was hospitalized for less than 24 hrs.  The copy of the said letter is marked at Exh.‘C-5’.  The Complainant thereafter by his reply dtd.25/01/2010 requested to the Opposite Party No.2 to review the matter in the light of letter dtd.08/01/2010 explaining the position.  The Complainant also requested to consider complete clause No.3.4 “The time limit of 24 hrs. will not applicable for mentioned surgeries/procedures and please see texts mentioned or any other surgeries/procedure agreed by TPA/Company which requires less than 24 hrs. hospitalization due to subsequent advancement in medical technology.  The copy of the said letter is marked as Exh.‘C-6’.  The Complainant thereafter on 08/04/2010 explained the situation  by giving the details of illness and procedure thereof requested to look into the matter to the Opposite Party No.2.  The copy of the said letter is marked as Exh. ‘C-7’.

 4)        It is submitted by the Complainant that thereafter we received a claim settlement voucher dtd.19/04/2010 alongwith a cheque of Rs.24,448/- thereby settling the claim.  It is contended that at the bottom of that letter, it was mentioned that “Any disagreement about the settlement shall be intimated to us within 10 days otherwise the same shall be being as your acceptance and full and final of the said claim.  The copy of the said letter is marked at Exh.‘C-8’.

5)        According to the Complainant, the claim of the Complainant was for Rs.59,184/-, however, the Opposite Party settled the claim for Rs.24,448/- and that too without any explanation as to why it was settled for less amount.  The said letter dtd.19/04/2010 was received by the Complainant on 11/05/2010.  The Complainant by letter dtd.14/05/2010 informed the Opposite Party that the said cheque of Rs.24,448/- was being accepted “under protest”. The copy of the said letter is marked as Exh.‘C-9’.  Then the Complainant again by his letter dtd.01/06/2010 clarified that the treating Dr. Dinesh Toprani, though Homeopathy Doctor, under Government Notification, certified that the said treatment was a recognized treatment. The Complainant therefore, contended that the deduction on that count was not permissible and requested to realize the balance amount.  The copy of the said letter is marked as Exh.‘C-10’,

 6)        The Complainant then on 20/09/2010 called upon the Opposite Party to settle the claim within 7 days from the date of the said letter and made grievance that inspite of the meeting with various officials, there was nobody to explain about the fate of balance amount.  The copy of the said letter is at Exh.‘C-11’.  He then issued final demand draft letter on 01/10/2010 and informed the Opposite Party that if the Opposite Party could not respond within 7 days from the date of that letter he will approach to the Consumer Court.  The copy of the said letter is marked at Exh.‘C-12’.  The Opposite Party No.2 upon receipt of the said letter by its letter dtd.08/10/2010 asked the Complainant to provide bill breakup towards Dr. Toprani’s consultation charges etc.  The copy of the said letter is marked at Exh.‘C-13’.  The Opposite Party by their letter dtd.18/10/2010 also asked the Complainant to comply with the requirements as called by the Opposite Party No.2.  The Complainant by letter dtd.28/10/2010 furnished the breakup as called for to the Opposite Party.  The copy of the said letter is marked as Exh.‘C-14’.  It is submitted that however, there was no response from the Opposite Parties thereafter, the Complainant therefore by his letters dtd.14/02/2011 and 28/03/2011 requested the Opposite Parties to redress the grievances. The copy of the said letters are marked as Exh.‘C-16’ colly. It is submitted that thereafter also the Complainant remained with constant touch with the Opposite Parties to settle the claim.  He made efforts on several dates.  In between 26/11/2009 to 23/02/2011, it is submitted that as there is inaction on the part of Opposite Parties it amounts to deficiency in service coupled with willful negligence as well as unfair trade practice on the part of Opposite Party.  The Complainant therefore, prayed for compensation of Rs.50,000/- towards mental agony, torture and inconvenience caused to the complainant.  The Complainant has also claimed balance amount of Rs.34,736/- together with interest @ 12% p.a. from the date of claim i.e. 23/11/2009 till its realization. The Complainant also prayed for cost of Rs.15,000/- towards this complaint.

 7)        The Opposite Party No.1 contested the claim by written statement. The Opposite Party denied the allegations made by the Complainant.  It is admitted that the Complainant’s wife required some medical treatment for dengue fever with Hypothyroidism and was admitted in Bombay Hospital on 06/10/2009.  It is denied that for the said medical treatment the Complainant had incurred an amount of Rs.59,184/-. It is contended that the Opposite Party No.2 as per the terms and conditions of the policy rightly repudiated the claim of the Complainant as per Exh.‘A’ to the written statement. It is contended that the Complainant has explained the events of the illness and treatment taken by his wife and has stated that since his wife’s gums were bleeding, the doctor need not want to take any chances and hence, advised her to be admitted in the hospital, but as per the letter of Doctor, dtd.07/01/2010, it was clearly submitted that the reason of admission was severe thrombocytopenia which may have lead to breeding. It is contended that hence, contrary submission has been made by the Complainant which clearly shows the intention of the Complainant to extract money from the Opposite Party. It is contended that the Opposite Party had taken the sympathetic approach towards the Complainant to settle the claim and hence, after scrutinizing the claim papers the claim settlement voucher was sent to the Complainant clearly mentioning that as per the terms and conditions of the policy, room rent + nursing charges are payable upto 1 % of the sum insured and since the sum insured was to the limit of Rs.4 Lac hence, Rs.4,000/- of one day as admission and the excess amount of Rs.2,900/- was deducted.  It is contended that the Complainant had submitted duplicate bill of Rs.1,930/- hence, the same was not payable.  The Complainant has submitted the bill of Dr.Toprani of Rs.24,490/- but as per the bill submitted by the Complainant clearly shows that various family members had visited the said doctor and which has been claimed by the Complainant.  It is contended that hence, the Complainant with malafide intention and just to extract more amount from the Opposite Party has put the bill of his family members visiting to the said doctor which is not payable and therefore, it was rightly deducted by the Opposite Party. It is also contended that similarly the other deductions has been justified by the Opposite Party since they were not payable as per the terms and conditions of the policy. It is contended that the Complainant cannot have grievance about the said deduction because even when the claim was not payable on account of less than 24 hrs. admission in the hospital.  It is contended that the Opposite Party has been taken sympathetic view and has paid legitimate claim of the Complainant the Complainant then also with malafide intention wants more amount without any justification.  Hence, the deduction was clearly justified by the Opposite Party as per Exh.‘B’ to the written statement.  It is contended that the breakup give by the Complainant was fabricated and given only on the queries of the Opposite Party.  It is contended that the Opposite Party has given the explanation of deduction and has justified the deduction as per the terms and conditions of the policy.  It is contended that the complaint is false and frivolous and must be dismissed with cost.  The Opposite Party No.1 denied that the Complainant has made out a case of deficiency in service coupled with willful negligence on the part of Opposite Parties.  The complaint filed by the Complainant is misconceived, false, bad-in-law and therefore, it may be dismissed with compensatory cost.     

 8)        The Complainant has filed his affidavit in support of his complaint. The Opposite Party No.1 has filed affidavit of Shri.S.R.Baig, Sr. Divisional Manager.  The Opposite Party No.2 remained absent though served with notice.  Hence, complaint is proceeded ex-parte against Opposite Party No.2.  The Complainant as well as the Opposite Party No.1 filed their written arguments.  We also heard the oral arguments of Shri. Ganesh Shirke, Ld.Adv. for the Complainant and Shri. B.S.Talwar, Ld.Adv. for Opposite Party No.1. The Ld.Advocate for the Complainant made same submissions as alleged in the written argument and relied the observations in the cases of Toorent Securities Pvt. Ltd. V/s. National Insurance Co. Ltd., 2007 CTJ 384(NCDRC) and M/s. Modern Insulators Ltd. V/s. The Oriental Insurance Co. Ltd. in Civil Appeal No.6895 of 1997 decided on 22/02/2000 by the Hon’ble Supreme Court of India, and submitted that in view of the observations in the aforesaid cases the claim made by the Complainant may be allowed.   The Ld.Advocate for Opposite Party No.1 Shri. Talwar, submitted that while repudiating the balance amount of Rs.34,736/- from the claim lodged by the Complainant by letter dtd.19/04/2010, the Opposite Party No.2 has specifically pointed out how the deductions are made from the total claim lodged by the Complainant.  He therefore, submitted that the Opposite Party has considered the just and proper claim after scrutinizing the medical papers and documents and accordingly issued cheque of Rs.24,448/- in favour of the Complainant.  He thus, submitted that the claim made in this complaint is liable to be rejected as there is no deficiency in service of the Opposite Parties.

 9)        While considering the entitlement of the claim made by the Complainant the documents which are filed by the Opposite Party No.1 which were submitted by the Complainant alongwith the claim lodged by him on 23/11/2009 are required to be taken into consideration.  The Complainant has submitted the bill of Bombay Hospital dtd.07/10/09 of Rs.23,706/-.  The Opposite Party allowed room rent + nursing charges of sum insured upto 1% i.e. Rs.4,000/- per day and deducted excess amount of Rs.2,900/-.  The Opposite Party also deducted Rs.1,930/- on account of duplicate bill and Homeopathic charges of Dr. Dinesh Toprani, of Rs.24,490/- and Rs.875/- for want of medicine breakup as well as Rs.205/- of hot water bag.  Rs.241/- on account of producing carbon copy bill and Rs.270/- of mussels spray, Rs.20/- bill tag and Rs.3,805/- towards surcharged.  We have perused all the copies of the bills produced by the Opposite Party No.1 alongwith its written statement. We hold that the deductions as above which are mentioned in the letter issued by Opposite Party No.2 dtd.19/04/2010 are just and proper.  The Opposite Party No.2 thereafter vide letter dtd.08/10/2010 again requested the Complainant for further processing they would request to provide the bill breakup towards Dr. Dinesh Toprani, consultation charges.  The Complainant by his letter dtd.28/10/2010 appears provided the bill details (breakup) of the bill Dr.Toprani, which is with Exh.‘C-14’ colly.  It appears that the earlier bill provided by the Complainant of Dr.Toprani alongwith the claim lodged by the Opposite Party No.1 and the bill breakup later on submitted alongwith Exh. ‘C-14’ i.e. letter dtd.28/10/2010 appears to be of different amount.  The earlier bill of Dr. Toprani was Rs.24,490/- and the bill breakup filed with the letter dtd.28/10/2010 by the Complainant is of Rs.15,600/-.  In both the bills the charges of some other family members of the Complainant such as, Ms. Swati Lath have been included.  In other bill breakup given by Dr.Toprani, dtd.25/10/2010, the charges of Sakshi Lath, Siddarth Lath appears to have been included.  In our view, Opposite Party No.2 has therefore, rightly rejected the bill of Dr. Toprani, towards Homeopathic charges of Rs.24,490/- which were submitted alongwith the claim lodged by the Complainant dtd.23/11/09.  We also hold that after the query made by Opposite Party No.2 vide its letter dtd.08/10/2010 the bill breakup of Dr. Toprani’s charges provided with the letter of Complainant dtd.28/10/2010 are inconsistent with the earlier bill of Dr. Toprani dtd.02/11/09 which was submitted alongwith the claim dtd.23/11/09.  By considering all the facts in our candid view the Opposite Party No.2 has rightly passed the claim for the amount of Rs.24,448/- by deducting Rs.34,736/- from the claim amount of Rs.59,184/-.  In our view the explanation given by the Complainant vide his letter dtd.14/05/2010 at Exh.‘C-9’ is not at all acceptable in view of inconsistent bills of Dr.Toprani placed on record by the Complainant.  Furthermore, the Complainant has not explained anything about the deductions made by the Opposite Party in regard to the duplicate bill, surcharge, hot water bag, duplicate bill, etc. to the Opposite Parties.  We therefore, hold that the Opposite Parties have rightly passed the claim which the Complainant was entitled on the basis of the genuine documents placed on record.  We hold that the Opposite Parties have allowed reasonable and proper claim from the amount of Rs.59,184/- to the tune of Rs.24,448/-.  The argument advanced by the Advocate for the Complainant Shri. Shirke relying on the observations in the cases cited Supra, in our view cannot be accepted as the same are not applicable to the facts of this case.  We therefore, hold that the Complainant has failed to prove that there is any deficiency in service by the Opposite Parties while deducting the amount of Rs.34,736/-.  The claim made by the Complainant against the Opposite Parties in our view is not legal and proper.  In the result we pass the following order -

O R D E R

i.                    Complaint No.189/2011 is dismissed with no order as to cost.

ii.                 Certified copies of this order be furnished to the parties.