This is an application u/s.12 of the C.P. Act, 1986.

The case of the complainant is that he had taken Mediclaim Insurance Coverage to the tune of Rs.1 lakh vide policy No.512902/34/09/11/00000328 from the OP/The New India Assurance Co. Ltd., for the period 20-09-2009 to 19-09-2010.

          It is the specific case of the complainant that on 05-05-2010 he was admitted that on S.V.S. Marwari Hospital on the advice of the doctor and was discharged on 04-07-2010.  The complainant spent Rs.1,38,913/- for his treatment of foot ulcer towards the medical expenses. 

          The complainant submitted the claim in a prescribed form along with all documents and original policy certificate before the office of the OP.  On 30-06-2011 the complainant received a cheque no.24893 amounting to Rs.69,003/- against the claim of Rs.1,38,914/- from the OP3.  According to the complainant, the OP in its letter dated 30-0-6-2011 have not shown any reason for such deductions about the less payment towards the total medical expenses incurred by him.  It is further stated by the complainant that the terms and conditions of the mediclaim policy issued by the OPs never and nowhere contains such terms and conditions and hence the rejection of the part claim of the complainant was arbitrary and contrary to the terms and conditions of the policy.  Hence, this case.

          In its written version, the OPs1 and 2 stated that the complainant was admitted to a hospital on 05-05-2010 where he had undergone necessary treatments followed by surgery on two occasions.

          The OP/Insurance Company resisted the claim and stated that the Mediclaim Policy was initially for a sum of Rs.1 lakh and it was enhanced b y adding the cumulative bonus occurred in respect of the stated mediclaim policy to the tune of Rs.34,250/-. 

          Fact remains that for the purpose of medical treatment/surgery of his right leg, the complainant was admitted to a hospital on 05-05-2010 where he had undergone necessary treatments followed by surgery on two occasions.  The complainant was released from the hospital on 04-07-2010 and a claim of Rs.1,38,914/- was lodged by him out of which the OP3 settled an amount of Rs.69,0003/- vide its letter dated 30-06-2011 and a cheque No.24893 dated 30-06-2011 drawn on HDFC Bank and the said amount of Rs.69,003/- was duly forwarded to the complainant after the deductions as against the alleged residual claim which were shown/recorded against the bills.  But upon consideration of the doctors certificate the OP3 ultimately further released of Rs.19,411/- by cheque No.036838 dated 09-05-2012 drawn on HDFC Bank in favour of the complainant.

          It is also stated that the OP3 duly forwarded a report in respect of non-admissible claim to the OP1 in accordance with the claim settlement.  Guidelines and the terms and conditions of the policy including exclusion clauses thereof, to the tune of a sum of Rs.50,500/-.  So, it is denied that the OPs ever adopted any unfair trade practice in order to harass the complainant.  In its submission, the OPs stated that as per terms and conditions of the policy and in accordance with the guidelines for the purpose of settlement of mediclaim, the claim for the complainant has already been settled to the aggregated tune of Rs.88,414/- and nothing more could be due and payable by the OPs to the complainant.

Decision with Reasons

Admittedly, the complainant and his wife had taken a Mediclaim Policy vide No.512902/34/09/11/00000328/5/2902 for the period from 20-09-2009 to 19-09-2010. 

          It is alleged by the complainant that after his treatment from the hospital, he submitted his claim of Rs.1,38,914/- out of which the OPs have settled only Rs.69,003/- and Rs.19,411/- respectively, but they could not give any clarification for such deduction of claim as submitted by the complainant.

          The main contention of the complainant is that the OPs are not entitled to deduct claim and repudiation of claim in part is unwarranted and illegal and thus, the issues have to be decided in its favour of the complainant i.e. aggregating total amount of Rs.88,414/- in accordance with the claim settlement guideline and the terms and conditions of the policy, including the exclusion clauses thereof and deducted of Rs.50,500/-.  It is also stated that a part of the cloaim has been repudiated which are not covered and payable under the subject policy and the cogent ground of repudiation of such claim is non-supply of the relevant information and documents including medical reports of the complainant.

          We have perused the documents filed by the complainant.  We have also considered the rival contention of the OP/Insurance Company.  Admittedly, the insured/complainant was under treatment at S.V.S. Marwari Hospital and had been covered under the mediclaim policy.  As per his treatment it shows that an amount of Rs.1,38,913/- was being incurred by the complainant.  The claim has been honoured by the OP/Insurance Company to the extent of Rs.88,414/- in favour of complainant under the purview, scope and ambit of conditions of the policy.  It is also described by the OP3 in its claim related details that the complainant was treated complications of foot and was hospitalized for a prolong period of 2(two) months w.e.f. 05-05-2010 to 04-07-2010 at S.V.S. Marwari Hospital, Kolkata.  Thereafter, the claim was forwarded to them by the insured vide claim form dated 21-01-2011 seeking reimbursement of treatment cost of Rs.1,38,913/- and the treatment sheet was submitted by the claimant on 18-03-2011 which was reviewed by the in house Medical Officer Dr. Sharma on 08-04-2011 who also had opined that prolonged hospitalization treatment for 2(two) months was not justified and major portion of hospitalization treatment could be done on domiciliary treatment basis.  Accordingly, clarification from treating doctor about the necessity of such prolonged stay vide letter dated 03-06-2011.  Since, Dr. R Nath submitted a certificate dated 07-06-2011 and accordingly the In-house Medical Officer approved vide settlement letter dated 21-06-2011 for the reasonable period of hospital stay till 03-06-2011.  And, as such, against total claim of Rs.1,38,914/- settlement allowed on payment of Rs.69,003/- and Rs.19,411/- respectively and was assessed of Rs.50,500/- as inadmissible claim as per claim settlement guidelines and terms and conditions of the policy of insured.

          We have considered the rival contention of the OP/Insurance Company.  Admittedly, the complainant was under the treatment at S.V.S. Marwari Hospital, Kolkata, w.e.f. 05-05-2010 to 04-0-7-2010 seeking reimbursement of treatment cost for Rs.1,38,913/-.  The OP/Insurance Co. settled the claim amounting to Rs.96,003/- and Rs.19,411/- respectively, i.e. total amount of Rs.88,444/-, but the due balance amount of Rs.50,500/- was assessed as inadmissible as per claim settlement guideline and terms and condition of the policy.  Under such situation, we gone through the records and the rev iew sheet of the concerned Medical Officer wherein we have observed that on the ground exclusion clause of the policy, the OP/Insurance Company did not reimburse the said amount of Rs.50,500/- on the ground of exclusion clauses as per terms of the policy.  Now, the crux of the case is whether the complainant is entitled the balance due amount of Rs.50,500/- for re-imbursement from the OP/Insurance Company as deducted by them on the ground of non-admissible under the terms of policy exclusion clauses 04-04-2017, 04-04-2021 and 04-04-2022.  The claim was registered vide CCN HH 241005203 and after scrutinizing the records the OP/Insurance Co. have made a further payment of Rs.19,411/- in full and final settlement and have been deducted of Rs.50,500/- on the ground of inadmissible on the plea of exclusion clauses under the rules laid down by the Insurance Authorities.  But fact remains that the complainant/patient incurred expenses for pathology charges, Eco-cardiography Test, X–ray, Colour, Medical Charges etc. i.e. approximately Rs.30,000/- had not been reimbursed due to non-submission of report from the side of the complainant.  Thus it can be said that the OP/Insurance Company must not take any irrelevant and extraneous consideration while arriving to a decision since the Insurance Policy is a social legislation and the primary/objective is to protect the insured in our considered view, the OP/Insurance Company should not deprive the total due balance claim of the complainant policy holder who submitted his claim of Rs.1,38,913/- and out of which the OP/Insurance Company had already cleared of Rs.69,003/- and Rs.19,411/- respectively and also further they should release/reimburse a sum of Rs.30,000/- from Rs.50,500/- in favour of the complainant without creating any plea for such non-submission of report from the side of the complainant.

          In the result, the complaint succeeds in part.

Hence,

Ordered

That the case be and the same is allowed on contest with cost of Rs.2,000/- against the OPs.

          OPs are directed to pay Rs.30,000/-(Rupees Thirty thousand only) as final claim amount in respect of one month from the date of this order failing which for disobeyance of the Forum’s order OPs jointly and severally shall have to pay punitive damages @Rs.100/- per day till full satisfaction of the decree and if it is collected same shall be deposited to the Head of the State Consumer Welfare Fund.  No other relief is answered in view of the present fact of the case.

          OPs are further directed to comply the order very strictly without any fail within one month failing which for n on-compliance of Forum’s order penal action may also be taken against them u/s.27 of the C.P. Act, 1986.

Dictated & Corrected

           by me