Per Mr.P.N.Kashalkar, Hon’ble Presiding Judicial Member

This is an appeal filed by the original complainant himself.  His complaint was allowed by the forum below and he was granted certain reliefs which earlier were negatived by the O.Ps. Facts to the extent material to dispose of this appeal may be stated as under:-

Complainant had already purchased Mediclaim insurance policies from O.P.no.1-M/s.New India Assurance Co.Ltd. He was a credit card holder of O.P.no.3-Citi Bank.  A representative of O.P.no.3 Bank somewhere in third quarter of 2003 approached the complainant with an offer to make payment of insurance policies through their credit card and avail discount on premium and the complainant is not required to go in for another policy.  Accordingly, the complainant opted for and paid premium through his credit card on 31/12/2004 and 31/12/2005, but the opponent/Insurance company converted Mediclaim policy to Good Health having different reimbursement slabs of which he was unaware.  The complainant had undergone Arthroscopy of Right knee at Bhatia Hospital on 15/1/2005.  The Opponent no.1/Insurance company reimbursed the expenses including T.V. camera, video charges and medicines and post hospitalization period of 60 days, finalized by the opponent no.2 and on 28/5/2005 the complainant again had undergone Angiography and Angioplasty at Asian Heart Institution, Bandra for which the opponent no.1-Insurance company reimbursed expenses only to the extent of 80%.  Hence, after enquiry, it was revealed that it is as per terms under the new reimbursement schedule, in relation to opponent no.3 –Bank, 80% of the total expenses were permissible and, accordingly, that was allowed.  However, grievance of the complainant is that he has sought clarification from M/s.TTK Healthcare Services Pvt.Ltd.-O.P.no.2 and had insisted that remaining balance 20% of the amount totaling Rs.42,600/- should also be reimbursed to him.  O.P.no.2 however replied that as per clause 1.1a of the Good Health policy conditions, under agreed package, all hospitalization expenses reimbursement are restricted to 80% of the total actual package charges.  Thereafter, wife of the complainant was admitted to Manna Hospital and she was operated on Uterus.  Her claim for reimbursement was allowed after deducting 20% as per Good Health policy conditions.  Grievance of the complainant is that he has not been paid 100% reimbursement charges and, therefore, he has filed consumer complaint for the deficiency in service of the opponents and claimed remaining balance amount towards the claim preferred by him under mediclaim policy.

O.P.no.1 resisted the claim by filing written version. According to O.P.no.1 claim was settled as full and final and was so accepted by the complainant and, therefore, he is estopped from agitating same point again. There is no cause of action. There is no liability to pay as prayed.  The complainant was covered under Good Health Policy since 01/01/2004 to 31/12/2004 for `3,00,000/- and on identical terms in subsequent years also.  The complainant’s claim was `2,17,269/-, out of which `1,74,144/- was approved and granted.  As per the terms and conditions, 80% amount was paid and 20% amount i.e. `43,125/- was disallowed.  The complainant claimed `69,894/- on account of his wife having undergone operation for Uterus of which company had paid `42,000/- which was 80% of the amount and claim of `27,894/- was refused since it was exceeding 80%.   Then fresh policy was issued to the complainant on proposal duly signed by the complainant.  It was not a conversion of his original Mediclaim policy and, therefore, there was no deficiency in service and they had allowed claims of the complainant and his wife under Good Health policy and not under Mediclaim policy.  Therefore, Insurance company pleaded that there was no deficiency in service on its part and had prayed that complaint should be dismissed with cost.

The O.P.no.2 after due service remained absent and did not file reply hence proceeded ex-parte by the forum below.

The O.P.no.3-Bank filed reply and resisted the complaint and pleaded that complaint is not tenable for misjoinder of party or non joinder of party.  No services were provided and, therefore, there was no deficiency on its part and, as such, it prayed for dismissal of complaint. 

After hearing advocate for the complainant and advocate for O.P.nos.1&3  forum below held that there was deficiency in service on the part of O.P.no.1-Insurance company in not granting full reimbursement as per the policy and, therefore, it allowed the complaint against O.P.nos.1 & 3 and directed  O.P.no.1 to pay `42,600/- and `27,894/- to the complainant  with interest @ 9% p.a. from the date of deductions within a month, from the date of receipt of order and O.P.no.3 –Bank was directed to pay `25,000/- as compensation to the complainant within a month.  But forum below disallowed prayer 26 (b) of his complaint, wherein complainant had asked the forum to issue necessary directions to the opponents to rectify the entry and register the applicant back to his original policy with opponent no.1 with continuity and without interference of the Citibank.  This prayer was not allowed by the forum below in its impugned judgement and award.  Hence complainant has filed this appeal.  Today when the matter is fixed for hearing, we found that appellant is absent. 

We heard Mr.A.S.Vidyarthi-Advocate for respondent nos.1 and 1a and Ms.Kejal Bang –Advocate for respondent no.3.

We are finding that there is absolutely no merit in the appeal preferred by original complainant.  Initially, he had taken Mediclaim policies from respondent nos.1 & 1a.  But all the claims which were allowed in favour of the complainant were under Good Health policy and under Good Health policy as per terms and conditions, only 80% of the hospitalization charges or of medical treatment can be reimbursed by the Insurance company and not 100%. Forum below however lavishly granted remaining 20% of the balance amount by allowing the complaint partly but forum below disallowed the prayer that direction should be given to Insurance company/respondent nos.1 & 1a to rectify the entry and register the applicant back to his original policy with opponent no.1 with continuity and without interference of the Citibank, since the day he first opted mediclaim policy.  This prayer was negatived and, therefore, this appeal is filed.  We are finding that such a prayer cannot be granted under Consumer Protection Act, 1986. What is important to note that initially complainant might have purchased Mediclaim policy but thereafter when he became credit card holder of O.P.no.3, he switched over to policy which was styled as ‘Good Health Policy’ and he continued to pay premium for ‘Good Health Policy’.  His policies were renewed from time to time as ‘Good Health Policy’ and not under ‘Mediclaim policy’ floated by respondent nos.1 & 1a and, therefore, such direction could not be given by the Consumer Fora while allowing the complaint.  Appeal therefore is appearing to be without any substance. In fact in place of 80% forum below has already granted 100% reimbursement and still it appears that complainant/appellant is not satisfied.  We cannot satisfy him by allowing this appeal partly.  Direction sought to be given to the Insurance company is beyond the jurisdiction of this Commission while deciding the appeal and, therefore, we are finding no substance in the appeal. As such, we pass following order:-

                                                ORDER

Appeal stands dismissed.

Parties are left to bear their own costs.

Copies of the order be furnished to the parties.