Order-11.

Date-20/05/2015.

Complainant Purushattom Boseby filing this complaint submitted that as a Mediclaim Policy Holder for long years, he has been continuing his mediclaim policy and it was ultimately renewed on 05.11.2013 being Policy No. 35010034130100000366 and validity period of the policy was from 06.11.2013 to 05.11.2014.

          Complainant has further submitted that in the said policy the details of TPA is noted as Medicare TPA Services Pvt. Ltd. and according to complaint when her mother became seriously ill reported the matter to TPA.  But they reported that his policy is not under the control of other TPA and further it was found that bonus was not found included in the policy and in the policy in place of Rs. 30,000/-, Rs. 5,000/- has been noted as bonus.  So, complainant went to the New India Assurance Co. P. Ltd. office for rectification and no doubt op rectified it after verifying all official document and issued a new policy document.

          Subsequently on 26.10.2014 the present complainant’s mother was hospitalized at Deshan Hospital for operation and operation was done on 27.10.2014 and on 28.10.2014 Prasanta Kumar Bose was admitted to Desun Hospital Kolkata as he was injured due to accidental fall over road and he was unable to send all claim documents to the Medicare TPA.  But the claim was not processed due to policy was not enrolled in their administration.  But subsequently they came to learn that Raksha TPA P. Ltd. is the TPA, but they failed to give any details.  Subsequently op informed that their TPA is Raksha TPA but policy was renewed with same TPA.  But in the meantime op released the part payment, but it is the submission of the complainant that for Priti Bose the total bill was Rs. 1,48,000/- and for Prasanta Kumar Bose Rs. 1,22,750/-.  But complainant did not get cashless benefit for such defect as noted in the policy against TPA and practically for wrong recording, complainant has been harassed and ultimately claim was settled by Raksha TPA Chandigarh released only Rs. 99,999/- on the ground the same insured has been exceeded and that bill was paid by the Raksha TPA against hospitalization of Prasanta Kumar Bose to the extent of Rs. 1,22,750/- and that TPA also resettled the claim of the complainant in respect of Priti Bose also on 04.11.2014.  But complainant was practically used the wrong record of the TPA and did not get cash benefit and further some amount was deducted from the insured amount.

          So, complainant for negligent and deficient manner of service filed this complaint for compensation of Rs. 15,000/- along with cost etc.

          On the other hand op Insurance Company submitted that all the claims of the complainant were disposed of.  Complainant received the entire amount.  No doubt there was an error regarding the name of Insured and that was reported and the matter was reported to Raksha TPA for realizing amount in respect of hospital cost of Prasanta Kumar Bose within one month from the date of discharge from the hospital.  So, there is no deficiency and negligence on the part of the op and further submitted that Rs. 564/- was deducted out of ambulance charges of Rs. 1,564/- on the ground 1 percent of the sum insured is payable and that was followed, Rs. 3,977/- was deducted against medical services as same is not payable for non-consumable item.  Moreover the sum insured total was Rs. 1,22,745/- out of which sum insured was Rs. 1,00,000/- but total payment was Rs. 99,999/- and deduction was Rs. 22,746/- and as per policy details.  So the patient paid a sum of Rs. 99,999/- against claim of Rs. 1,22,745/-.  In fact Rs. 3,977/- could not be paid since coming under non consumable item and restricted under policy condition 4.4.21 and in fact Priti Bose was admitted on 24.10.2014 and her claim was disbursed on 07.11.2014 whereas Prasanta Kumar Bose was admitted on 27.10.2014 and it was also disbursed in the month of November 2014 and all the claims were decided and disbursed finally within one month.  So, there is no negligence and deficiency on the part of the op and in fact with some motive to collect some more money, this complaint is filed for which it shall be dismissed but without cost.

                                                     Decision with reasons         

          On proper consideration of the entire complaint and the written vfersion and also considering the admitted position that out of claim of Rs. 1,22,745/-,Rs. 99,999/- has already been paid and disbursed.  Subsequently Rs. 18,205/- was also paid to the insured under claim No. 9051415197449.  It is also proved that op has also paid the entire amount after small deduction as per clause against claim No. 9051415168899 and in this regard we have seen that their calculation as drawn wherefrom we have gathered that op calculated single room fee, doctor and investigation fees, hospital charges, medicine charges properly as per policy clause deduction is also made properly.

          So, there is no legality for deducting such amount which has not been released.  But in respect of cumulative bonus of Rs. 30,000/- the dispute as raised by the complainant had already been regularized and balance amount of Rs. 18,205/- was also regularized and it was paid after settlement a sum of Rs. 9,674/- also.  Considering all the above fact and materials and the extract of policy conditions, it is clear that there is no deficfiency or negligence on the part of the op and deduction of Rs. 3,977/- (as challenged) by the complainant is found correct in view of the fact that the said amount was not paid to the complainant for non-consumable item and as per policy, for non-consumable item, no claim can be made by the complainant and op rightly deducted it.

          Considering all the above fact and materials we have gathered that a vexatious complaint is filed by this complainant and in fact we are not searched out any unfair practice of the op in this regard for settling the claim and truth is that claims were disposed within one month of both the cases from the filing of the claim as complainant did not get any cashless benefit. 

          In the result, we find that there is no merit in this complaint for which this complaint fails.

          Hence, it is

                                                         ORDERED

          That the complaint be and the same is dismissed on contest against the ops but without any cost.