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

1)        By this complaint the Complainants have prayed that the Opposite Party be directed to correct the policy and renew it as per the original terms and condition in favour of Complainant No.2. It is also prayed that the Opposite Party be directed to pay balance claim of Rs.87,186/- to the Complainant No.2 with interest @ 12% p.a. from 11/05/2012 i.e. the date of partial settlement of the claim till realization of the balance claim amount.   It is also prayed that the Opposite Party be directed to pay compensation of Rs.20,000/- to the Complainant No.2 for causing mental tension who is a senior citizen of 80 years old and cost of this complaint.

2)        According to the Complainants, the Complainant No.1 is voluntary consumer organization which has been espousing the cause of consumers.  The Complainant No.2 is the actual aggrieved consumer.  The Complainant No.2 is ensured with the Opposite Party under mediclaim policy since past several years and the policy has been renewed from time to time.  The copy of the policy which was inforce at the material time for the period 31/03/2011 to 30/03/2012 is marked as Exh.‘A’.  As per the said policy the sum insured there under was Rs.1,00,000/- and the cumulative bonus was Rs.50,000/- and as such, aggregate amount for getting benefit by the Complainant No.2 was to the tune of Rs.1,50,000/-. It is submitted that the Complainant No.2 was suffering from left in Inguinal Hernia during the policy period and he was operated at Breach Candy Hospital where he was hospitalized from 25/03/2012 to 28/03/2012.  The Complainant No.2 lodged claim with the Opposite Parties processing agent, M.D. India Healthcare Service (TPA) Pvt. Ltd. for Rs.1,83,219/-. It is submitted that however, the TPA sanctioned the claim for Rs.62,814/- only.  The copy of the claim payments statement and the cheque issued for the sanctioned amount by it are marked as Exh.‘B’ & ‘C’. According to the Complainants, on perusing the reasons for sanctioning only a part amount of the claim it was noticed that the deductions were made on account of changes in the policy terms and conditions which were made without the knowledge and consent of the Complainant No.2. The copies of the earlier policy showing the original terms and conditions are marked at Exh.‘D’. The Complainant’s have alleged that the unilateral changes in the terms and conditions of the policy are illegal and contrary to the law laid down by the Hon’ble Supreme Court in the case of Biman Krishna Bose V/s. United India Insurance Co. Ltd., (III) 2001 CPJ 10 (SC).  The Complainants thus, claimed that the Opposite Party ought to have paid Rs.1,50,000/- which was the maximum coverage available to the Complainant. The Complainant has therefore, prayed the reliefs as mentioned in para no.1 of this order. 

3)        The Opposite Party filed written statement and contested the claim made in the complaint.  It is contended that the claim of the Complainant No.2 was partly admitted and paid after scrutinizing the claim to the tune of Rs.62,814/- in view of non admissible amount as per policy clause no.2.1 and as per note applicable to the policy clause no.2.3 and 2.4 of mediclaim policy (2007).  It is contended that the Complainant No.2 has accepted the compensation in full and final settlement and therefore, he has been prohibited from proving anything in contradiction to what he has accepted.  It is contended that whatever has been stated by the Complainant is stated with malafied intention and with alterative motive and the same can never be treated as deficiency of service. It is denied that the Complainant is entitled to any amount, interest on claim amount, compensation for mental torture and cost of the litigation.  The Opposite Party has denied all the parawise allegations made in the complaint and submitted that the complaint be dismissed with exemplary cost.

4)        The Complainants have not filed separate affidavit of evidence besides the affidavit filed with the complaint. The Opposite Party has filed evidence of affidavit of Ram Narayan Chakravarti, Sr. Divisional Manager.  Both the parties filed their written arguments.  We heard the oral arguments of Shri. Jehangir Gai, Representative of Complainants and Smt. Kalpana Trivedi, Ld.Advocate for the Opposite Party. We have perused the documents filed by the Complainants.

5)        While considering the claim made in the complaint it is necessary to be taken into consideration that the Complainant No.2 has obtained first mediclaim policy on 30/03/1999 and it was continued till the relevant period of this case. The Complainants have filed the premium receipt issued by the Opposite Party for the period 30/03/2004 to 29/03/2005 at Exh.‘D’ and the copy of Mediclaim Insurance Policy (01/09/1996).  On perusal of the terms and conditions of the said policy the submissions made by the representative of the Complainants that it did not have any sub-limits restricting the room charges, ICU charges can be said just and proper. His further submission that various terms were included in new policy terms & conditions, and that too without the knowledge and consent of the Complainant No.2 can be said legal and proper. The Opposite Party has not placed on record any document showing that the terms and conditions of the new policy were accepted by the Complainant No.2 in writing. The Opposite Party has not produced any record showing that the Complainant No.2 was informed about the changes in terms and conditions of Mediclaim Insurance Policy (01/09/1996) in the new policy issued by the Opposite Party Mediclaim Policy (2007).  The Hon’ble Supreme Court in the case of Biman Krishna Bose V/s. United India Insurance Co. Ltd., reported in III (2001) CPJ 10 (SC) have observed as under –

“A renewal of insurance policy means repetition of the original policy.  When renewed, the policy is extended and the renewed policy in the identical terms from a different date of its expiration comes into force.  In common parlance, by renewal, the old policy is revived and it is sort of a substitution of obligations under the old policy unless such policy provides otherwise.  It may be that on renewal, a new contract comes into being, but the said contract is on the same terms and conditions as of the original policy.”

            Considering the aforesaid observations in our view the prayer made by the Complainants to direct the Opposite Party to renew the policy as per original terms and conditions incorporated in mediclaim insurance policy (01/09/1996) is legal and proper.  On perusal of the old policy terms and conditions as there were no clauses restricting the mediclaim charges paid by the Insured as mentioned in Exh.‘B’ by the agent of the Opposite Party i.e. MD India Healthcare Services (TPA) Pvt. Ltd, in our view the Opposite Party has wrongly deducted an amount of Rs.87,186/- in view of coverage available to the Complainant No.2 to the tune of Rs.1,50,000/-.  In view of the aforesaid discussion the deduction made in Exh.‘B’ by the Opposite Party is nothing but the deficiency in service in making the payment which was liable to be made by the Opposite Party.  We therefore, hold that the Complainant No.2 is entitled for an amount of Rs.87,186/- as prayed in the complaint towards the medical reimbursement charges from the Opposite Party. The contention raised by the Opposite Party that the Complainant No.2 had accepted an amount of Rs.62,184/- as full and final settlement and therefore, the claim made in the complaint is liable to be rejected cannot be accepted.  In the document at Exh.‘B’ there is no mentioned that the amount which is offered to the Complainant is offered by the TPA of Opposite Party as full and final settlement.  The submissions therefore, made by the Advocate for the Opposite Party in that regard cannot be accepted as legal and proper.  The claim made by the Complainants for grant of compensation of Rs.20,000/- to the Complainant No.2 for mental tension in our view is exorbitant. In our view an amount of Rs.8,000/- would be just and proper for such compensation. The Complainants have claimed interest on the amount of Rs.87,186/- @ 12% p.a. from 11/05/2012 in our view interest @ 9% p.a. on the said amount from the said date till realization of the said amount would be justified.  The Complainant No.2 is entitled for cost of Rs.3,000/- towards this complaint.  In the result the following order is passed –

O R D E R

i.      Complaint No.181/2013 is partly allowed against the Opposite Party.

            ii.      The Opposite Party is directed to renew the policy in favour of the Complainant No.2 as per the original terms and conditions of 

                     Mediclaim Insurance Policy (01/09/1996).

           iii.      The Opposite Party is directed to pay Rs.87,186/- (Rs. Eighty Seven Thousand One Hundred Eighty Six Only) with interest @ 9%

                     p.a. from 11/05/2012 till the realization of the said amount and Rs.8,000/- (Rs. Eight Thousand Only) towards compensation for   

                     mental agony and inconvenience caused to the Complainant Nos.2 and Rs.3,000/- (Rs.Three Thousand Only) towards this

                     complaint to the Complainant No.2.

          iv.       The Opposite Party is directed to comply order in para ii & iii of the aforesaid order within one month from the date of service of this

                     order.

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