Per Sh. Rakesh Kapoor, President

The complainant is holder of Janta Mediclaim Policy  (JMP)  issued by OP-1. During the subsistence of the said policy, his wife was hospitalized on 1.6.2012 and was operated upon for DUB. She was  discharged on 4.6.2012.  The complainant had lodged a claim for a sum of Rs.53,787/- incurred on the aforesaid treatment.  OP-1 however, had settled the claim for a sum of Rs.22,500/- ONLY.  The complainant has alleged that the deduction of a sum of Rs.31,287/- from the claim lodged by him is illegal and unwarranted. Hence the complaint.

The OPs have contested the complaint and have filed a W.S.  Paras 3 & 4 of the preliminary objection of the W.S. read as under:-

3.That in the terms and conditions/schedule of the policy the expenses reimbursable for various illness/Operation where/are categorically mentioned.  The schedule shows that reimbursable maximum charges inclusive of Room/ICU/OT charges/Surgeons.  Anaesthetist, doctors, fees, medicines, internal appliances, and t he charges incurred during hospitalization period for “Hysterectomy” was Rs.22,000/- which has admittedly been received by the complainant hence his claim of amount in excess of the limit is misconceived and without any basis. 

4.That the wife of the complainant was treated for DUB and underwent Total Laparoscopic Hysterectomy (TLM) and the maximum coverage for the said treatment has been reimbursed by the O.P hence the present petition is not maintainable.

     OP-1 has contested the complaint on merit.  It has admitted that the complainant, his wife and children were covered under JMP for the period 12.6.2011 to 11.6.2012.  It has, however, claimed that the amount due under the policy has already been released to the complainant.  It has claimed that it has acted under the terms and conditions of the policy purchased by the complainant.  It has therefore, prayed that the complaint be dismissed.

       We have heard arguments advanced at the bar and have perused the record.

     The facts are not much in dispute.  The complainant and his family were covered under JMP issued by OP-1.  During the subsistence of the said policy, the wife of the complainant had undertaken a Laparoscopic Hysterectomy.  The complainant had lodged a claim for Rs.53,787/- on account of expenses incurred on the above treatment.  OP-1, however, had settled the claim for Rs.22,000/-.  The Ld. Counsel for OP-1 has drawn our attention to Annexure – A, B  which prescribe a maximum limit of payment for expenses incurred against different disease.  Annexure A-2 prescribes a maximum limit for a Hysterectomy to the tune of  Rs.22,000/-.  Admittedly, this amount has been paid to the complainant.  We therefore, hold that there is no deficiency in service on behalf of the OPs as the amount payable under the policy had already been released to the complainant.  OP-1 had acted in  accordance with the terms and conditions of the policy.  We, therefore, see no merits in this complaint.  The same is hereby dismissed.

Copy of the order be made available to the parties as per rule.  File be consigned to record room.

Announced in open sitting of the Forum on.....................