The present complaint case is filed by one Sri Rajat Kanti Roy against Oriental Insurance Co. Ltd. and M/s Vipul MedCorp TPA Pvt. Ltd., praying for a direction upon OPs to pay the differential amount of Rs. 11,990/- together with compensation for a sum of Rs. 50,000/- and litigation cost.

Case of the Complainant, in short, is that, he is the holder of a mediclaim policy being no. 311604/48/2015/1903.  He is paying requisite premiums in respect of this policy for the last 12 years.  Further case of the Complainant is that, his wife had to be hospitalized at Ruby General Hospital on 25-04-2015.  Subsequently, post-surgery, the patient was released from the hospital on 02-05-2014.  It is alleged that although the Complainant was billed Rs. 88,802.25, he was reimbursed only a sum of Rs. 75,000/-, that too after lot of persuasion and rest of the amount had to be deposited from his own coffers.  Complainant, thereafter, sent two bills to the OP No. 2 – one pertaining to hospitalization period amounting to Rs. 14,332.00, out of which the OPs arbitrarily deducted Rs. 10,790/- and the second one for post hospitalization period for a sum of Rs. 3,610/-, out of which too the OP No. 2 arbitrarily deducted Rs. 1,200/-.  Total deduction made by the OP No. 2, thus, figured out at Rs. 11,990/-.  Complainant made several correspondences with the OPs, but to no good effect. Finding no other alternative, Complainant filed this case.

On the basis of such pleadings, the case was admitted and notice duly served upon both the OPs.  However, none of them turned up to defend their case.  Accordingly, the case was taken up and heard ex parte against them.

The solitary point for determination is whether or not the Complainant is entitled to the reliefs sought for by him.

Decision with reasons

In support of his contention, Complainant filed copies of concerned insurance policy, discharge summary issued by Ruby General Hospital, in-patient bill dated 02-05-2015, copy of email correspondences exchanged between the parties, legal notice dated 22-03-2016.

It is stated by the Complainant that the OP Insurer deducted a sum of Rs. 10,790/- from the bill pertaining to hospitalization period and another sum of Rs. 1,200/- was deducted against the bills submitted for post-hospitalization period.

Curiously, save and except one bill of Ruby General Hospital for a sum of Rs. 88,802.75, the Complainant has not submitted any supporting document.  Thereby, we are virtually left with nothing to ascertain the veracity of his allegation.  Having access to relevant documents assumes greater significance in view of a discrepancy that comes to fore over scrutiny of available documents on record. We notice from the copy of legal notice dated 22-03-2016 that the Complainant therein admitted the fact of receiving a sum of Rs. 81,000/- as cashless benefit; whereas, it is stated in the petition of complaint that the Insurer only paid Rs. 75,000/- and rest of the hospital bill amount was borne by the Complainant himself.  Unfortunately, no explanation is put forth from the side of the Complainant in this regard.

In any case, it is common knowledge that the entire bill amount is not paid by Insurers, certain deductions are made from the billed amount in terms of the policy conditions, e.g., although the hospital authority charged Rs. 10,500/- as bed charges, Complainant was entitled to get reimbursement of Rs. 4,500/- under the concerned package.  Similarly, the hospital authority charged Rs. 14,740/- for carrying out different investigations, but package entitlement on this score has been figured out at Rs. 1,500/-. Now, whether there was any inconsistency in respect of the package entitlement as shown in the bill, it was incumbent upon the Complainant to point out the same.  Unfortunately, we find that, the Complainant has not treaded such path, but simply hurled accusation against the OPs.  We must emphasize that; mere allegation does not prove anything.  Thus, in absence of cogent documentary proof and proper explanation, as pointed out hereinabove, we are afraid; no relief can be accorded to the Complainant.

Hence,

O R D E R E D

that CC/295/2016 be and the same is dismissed ex parte against the OPs.  No order as to costs.