PER SHRI. S. G. CHABUKSWAR – HON’BLE  MEMBER

1)        This is a complaint for the reliefs against the Opposite Parties for Rs.60,870/- hospitalization expenses with interest @ 12% p.a., Rs.20,000/- compensation for mental agony and Rs.10,000/- cost of the complaint.

2)        The case of the Complainant in short is as under –

The Complainant has been insured with the Opposite Party No.1 under Mediclaim Policy since more than 8 years prior to the complaint.  The Complainant and his family is covered under Mediclaim Policy No.112700/34/07/11/00012409 for the period from 04/03/2008 to 03/03/2009 for total sum insured of Rs.1,00,000/- and bonus Rs.42,000/- i.e. total Rs.1,42,000/-.  During the currency of above mediclaim policy the Complainant was required to take treatment in Lilavati Hospital for the period of 22/07/2008 to 29/07/2008 for ‘R’, Buccal Mucosa–Submucosal Fibrous Lesion and incurred expenses of Rs.60,870/-.  He had submitted insurance claim for Rs.60,870/-. The Opposite Party No.2 wrongly repudiated the claim by the letter dd.18/01/2010. Thereafter, the Complainant made correspondence with the Opposite Party No.1 but the Opposite Party No.1 also confirmed the repudiation of claim by the letter dtd.29/10/2010. The Opposite Parties have rejected the claim of the Complainant on the ground that present ailment is related to Supraglottic CA, and the claim made by the Complainant in the year 2004 has been rejected under clause 4.8 for Supraglottic CA.  This claim has also been rejected.

3)        The further case of the Complainant is that, after repudiation of his claim by the Opposite Parties of the year 2004, he had filed Consumer Complaint No.DF/MSD/177/05 before the District Consumer Forum Mumbai Suburban. The said complaint has been allowed by the said Forum on 29/06/2007.  The Opposite Party had preferred First Appeal No.1222/2007 against the order passed by the District Consumer Forum before the Hon’ble State Commission, Mumbai.  The said appeal has been dismissed by the Hon’ble State Commission on 10/07/2009.  Thereafter, the Opposite Party settled the claim of the Complainant for hospitalization of the period 08/04/2004 to 22/04/2004 by Cheque No.19251420, dtd.04/03/2011 drawn by Axis Bank for Rs.2,14,894/-. The Opposite Party No.1 & 2 have adopted unfair trade practice & deficiency of service by repudiating the claim of the Complainant of the period 22/07/2008 to 29/07/2008. Hence, this complaint for the reliefs mentioned in above para no.1

4)        The Opposite Parties have resisted the claim by filing written statement on 28/08/2013.  The Opposite Parties have admitted that Complainant had underwent treatment for wide laser excision of Buccal Mucosa Rt. side at Lilavati Hospital from 22/07/2008 to 29/07/2008 for which the claim of Rs.60,870/- was lodged with the Opposite Party No.1. Opposite Party No.2 being the TPA of Opposite Party No.1 repudiated the claim of the Complainant on the ground that patient came with complaint of Buccal Mucosa CA and underwent wide laser excision during hospitalization, as present ailment is related to Supraglottic CA and the claim lodged by the Complainant in the year 2004 has been rejected under clause 4.8 for Supraglottic CA.  However, on the request of the Complainant, the Opposite Party reassessed the claim of the Complainant and amount of Rs.57,757/- was sanctioned on 16/01/2012 which the Complainant had refused to accept. The Opposite Parties have denied that they are guilty of deficiency in service and unfair trade practice. The Opposite Parties have denied all rival allegations of the Complainant and prayed for dismissal of complaint with compensatory cost.

5)        The Complainant had submitted his affidavit of evidence and documents alongwith the complaint.  The Opposite Parties have submitted affidavit of evidence of Divisional Manager.  Both parties have filed their written notes of arguments.

6)        The Opposite Parties had repudiated the claim of the Complainant of the treatment of Lilavati Hospital of the period 22/07/2008 to 29/07/2008 on 18/01/2010.  However, in the month of January, 2012, Opposite Party No.1 reassessed the claim of the Complainant and amount Rs.57,757/- was sanctioned.  The Complainant refused to accept the said amount.  The Opposite Party No.1 has not given any reason as to why they had sanctioned claim for Rs.57,757/- instead of Rs.60,870/-.  The Opposite Party No.1 has not given any explanation as to why they have reduced the claim by Rs.3,113/-.  Hence, the Complainant has rightly refused to accept the said amount.  The Complainant has submitted with Opposite Party original medical receipts alongwith the claim form.  It means the Opposite Parties have verified the amount of medical expenses made by the Complainant. The Opposite Party No.1 has reassessed the claim on 16/01/2012 after two years from the first repudiation letter dtd.18/01/2010.  The Opposite Party has also not given any reason as to why they taken two years time for reassessment of the claim.  All theses facts show that the Opposite Parties have adopted unfair trade practice and there is deficiency in service.  In view of this, we hold that Complainant is entitled to Rs.60,870/- towards medical expenses with interest @ 6% p.a. from 29/10/2008 till it’s realization as claimed by the Complainant though he lodged the claim to Opposite Party No.2 on 10/10/2008.  The Opposite Parties do pay Rs.3,000/- towards compensation and Rs.2,500/- for cost of the complaint. 

         In the result complaint deserves to be partly allowed.  Hence, we proceeds to pass following order –

                                                                                                  O R D E R

                   i.     Complaint No.02/2012 is partly allowed with cost against Opposite Parties.

ii.     Opposite Party Nos.1 & 2 are directed to pay to the Complainant Rs.60,870/- (Rs. Sixty Thousand Eight Hundred Seventy Only)

        towards medical expenses with interest @ 6% p.a. from 29/10/2008 till the realization of said amount.

                  iii.     Opposite Party Nos.1 & 2 are directed to pay to the Complainant Rs.3,000/-(Rs. Three Thousand Only) towards compensation for

                          mental harassment caused to him.

           iv.     Opposite Party Nos.1 & 2 are directed to pay to the Complainant Rs.2,500/-(Rs. Two Thousand Five Hundred Only) towards the

                   cost of complaint.

                   v.    Opposite Party is directed to pay the amount mentioned in above para Nos. ii, iii & iv to the Complainant within 45 days from the

                          date of service of this order.

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