Complainant Alka Gupta through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that necessary directions may kindly be issued to the opposite parties to make payment of remaining amount of Rs.1,60,000/- qua her claim immediately in terms of the insurance policy alongwith interest @ 18% per annum from the date of due till actual realization. Opposite parties be further directed to pay Rs.50,000/- as compensation on account of mental agony, physical harassment and deficiency in service on the part of the opposite parties alongwith Rs.5,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that she is insured with the opposite party no.1 under the Mediclaim Policy No.1111002815P105793342. The opposite party no.2 is third party Administrator (TPA) as service provider and are responsible for providing the services to the insured as per the terms and conditions of the insurance policy and standing as the privity of contract for both the opposite parties. She has next pleaded that she has undergone treatment for her coronary angiography, coronary stenting and staged angioplasty at Fortis Escorts Heart Institute, New Delhi, where she remained hospitalized from 22.11.2015 upto 28.11.2015 following her treatment under due intimation through the hospital authorities to the opposite parties. She spent Rs.4,68,409/- on her treatment in the abovesaid hospital. The hospital in question is duly incorporated in the record of hospitals. As per the Insurance Policy, the opposite parties have assured her to indemnify her Rs.3,00,000/- in claim lodged for any illness, whereas the opposite parties have paid only Rs.1,40,000/- to her, whereas she spent Rs.4,68,409/- on her treatment. Since under the Mediclaim policy the sum to be indemnified is Rs.3,00,000/- as such she was indemnified to that extent, but the opposite parties instead of indemnifying Rs.3,00,000/- have paid only Rs.1,40,000/- to the hospital authorities without assigning any valid and legal reason for making short payment of Rs.1,60,.000/- for which the opposite parties are liable to pay as per the terms and conditions of the policy. On account of this lapse on the part of the opposite parties, she under compelling circumstances paid balance amount of Rs.1,60,000/- which opposite parties are liable to pay to the hospital. Even as per admission of making payment of Rs.1,40,000/- to the hospital authority, the opposite parties are liable to pay the sum assured of Rs.3,00,000/-. The opposite parties by not making payment of full insured amount of Rs.3,00,000/- are trying to back out from their obligations of making payment of the sum assured. Act of the opposite parties of not making full payment of sum assured, has caused mental agony, harassment and financial loss to her. He also served notice dated 29.3.2016 to the opposite party requesting them to make remaining amount of Rs.1,60,000/- alongwith interest but they have not taken any action into the matter. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.

3.       Notice of the complaint was served upon the opposite parties. Opposite party no.1 appeared through its counsel and filed its written reply by taking the preliminary objection that present complaint of the complainant is not maintainable and the complainant has no cause of action to file the present complaint. On merits, it was submitted that it was correct that the opposite party no.2 is third party Administrator (TPA) as service provider, but he is duty bound to go beyond the terms and conditions of the Insurance Policy. It was wrong that the complainant undergone treatment for her coronary angiography, coronary stenting or staged angioplasty at Fortis Escorts Heart Institute, New Delhi or where the complainant remained hospitalized from 22.11.2015 upto 28.11.2015 following her treatment as alleged. Rather as per the Hospital Bills the date of admission has been mentioned as 21.12.2015 and the date of discharge has been mentioned as 24.12.2015. It was next submitted that the claimant is claiming the total sum insured i.e. Rs.3,00,000/-, whereas Hospital Authority submitted the bills worth Rs.1,40,000/- which the insurance company has duly paid through TPA. As such the complaint of the complainant is against the Insurance Policy of the Insurance Company and is liable to be dismissed with costs and be dismissed with compensatory costs as the same has been filed just to harass the officials of the Insurance Company. It was wrong that the complainant spent Rs.4,68,000/- on her treatment in the said Hospital. It was correct that opposite parties have assured the complainant to the tune of Rs.3,00,000/-. It was submitted that the opposite parties had paid the amount of Rs.1,40,000/- to the complainant against the Bills submitted by the Hospital and as per the terms and conditions of the Policy. Insurance company is duty bound to release the amount subject to the Hospital Bills against the sum assured and not above the sum assured, but in the present case the amount Hospital Bills were worth Rs.1,40,000/- which the company has duly paid by TPA without any delay. The opposite party is not liable to make the excess amount that the Hospital bills. Thus, there is no deficiency in service on the part of the opposite parties. All other averments made in complaint have been denied and lastly prayed for dismissal of the complaint with exemplary costs.

4.       Notice issued to the opposite party no.2 had not been received back. Case called several times, but none had come present on its behalf, therefore, it was proceeded against exparte vide order dated 24.4.2017.

5.       Counsel for the complainant tendered into evidence affidavit of Alka Gupta complainant Ex.C1 along with other documents Ex.C2 to Ex.C21 and closed the evidence.

6.       Counsel for the opposite party no.1 tendered into evidence affidavit of C.S.Thakur Ex.OP-1/1 along with other documents Ex.OP-1/2 and Ex.OP-1/3 and closed the evidence.

7.     We have thoroughly examined the available documents/evidence on the records so as to interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants measured against the back-drop of the arguments as put forth by the learned counsels for their respective-side clients. We find that the present dispute has arisen at the alleged partial payment/settlement of the complainant’s hospitalization expenses by the OP1 insurers. The complainant has deposed (affidavit Ex.C1) having incurred Rs.4,68,409/- as hospitalization expenses (Ex.C10) on her medical treatment at the Fortis, New Delhi; whereas the OP1 insurers did arbitrarily pay Rs.1,40,000/- only (Ex.C9) towards their reimbursement share contribution to the hospital authorities against an assured sum of Rs 3.0 Lac per the related terms of the related health policy (Ex.OP1/2) as duly held by the complainant.

8.      The OP1 insurers have in turn pleaded vide its written statement (affidavit Ex.OP1/1) that the payment of Rs.1,40,000/- has been appropriately/accurately paid by them in terms of the policy that cover actual ‘hospital-expenses’ only or up to 70% of ‘sum-assured’ which so ever has been less of the two and the ‘process-sheet’ Ex.OP1/3 proves the same.

9.       That, somehow the learned counsel for the complainant insists during the course of arguments that there has been a definite hue of ‘unfair trade practice’ and ‘deficiency in service’ on the part of the insurers and as such the present complaint deserves an audacity in line with the superior court judgments on parallel ratio issues. However, no such citation has been either made during the course of arguments or put forth vide the arguments as duly submitted in writing and held on records. We cannot but proceed ahead with our findings.

10.     In the light of the all above, we are of the considered opinion that the impugned settlement of the instant insurance claim has been in order and in conformity with the terms of the related insurance policy and thus we ORDER for ‘dismissal’ of the present complaint. The parties shall bear their own costs here and ’shall also be at liberty to avail of any other legal remedy in law as per their choice and available advice.

11.     Copy of the orders be communicated to the parties free of charges. File is ordered to be consigned to the record room.

                                                        (Naveen Puri)                          

                                                President                              

                                            (Jagdeep Kaur)

Announced:                                        Member     

December 15, 2017.                

*MK*