The instant case was started on the basis of a petition of complaint filed by one Sri Anup Kumar Agarwala, of Sarbamangalapally, under the P.S. English Bazar, P.O. & Dist.- Malda and the said petition of complaint was registered before this Forum, as Consumer Case No. 23 of 2017.

 The fact of the case as revealed from the petition of complaint as well as from the evidence is that the petition purchased one Mediclaim Policy in the name of his daughter viz. Neha Agarwala who is a student. At the time of purchasing the said Mediclaim Policy which bears the No. 031400/48/13/97/00001/2454 for the year 2000 and subsequently the said policy was renewed from time to time and the said policy was valid from 28/02/2014 to 27/02/2015.

The daughter of the complainant Neha Agarwala unfortunately met with an accident in July, 2014 and got serious ankle injury and she was treated at Apollo Hospital at Chennai and the doctor advised her to undergo surgery for which the date of surgery was fixed on 15/08/2014. On the basis of the advise as rendered by the doctor the daughter of the complainant was undergone ankle surgery at Apollo Hospital at Chennai on 15/08/2014. It has been further stated by the complainant that the complainant intimated the O.P. about the date of operation by letter on 14/08/2014 which the O.P. received the same but the O.P. did not respond to the letter. After operation the complainant submitted a bill of operation of his daughter amounting to Rs.1,23,123/- (Rupees One Lakh Twenty Three Thousand One Hundred Twenty Three Only) along with all vouchers and receipts to the O.P. But the O.P. only sanctioned a sum of Rs. 62,385/- (Rupees Sixty Two Thousand Three Hundred Eighty Five Only) and the amount was sent through NEFT on 24.12.2014 by adopting the unfair trade practice. Thereafter the petitioner sent several letters but ultimately the O.P. did not give any reply. This is why the complainant has come to this Forum to redress his grievances.

The petition has been contested by the O.P. Insurance Company i.e. the United India Insurance Co. by filing a written version denying all the material allegations as leveled against the Insurance Company contending inter alia that the complainant has no right to file this case against the O.P. The case is bad for non-joinder of necessary parties. The case is barred by principle of waiver, estopel and acquiescence. The further is that the complainant did not follow the terms and condition of the medi-claim policy. The O.P. after calculation found that the complainant is entitled to get Rs.62,385/-(Rupees Sixty Two Thousand Three Hundred Eighty Five Only)as such the amount was sent to the account of the complainant through NEFT. As such the O.P. did not adopt any unfair trade practice. Considering such facts and circumstances the instant case is liable to be dismissed.

 In order to prove the case the complainant was himself examined as PW-1 and cross-examined. During the trial he has proved and marked the document from Ext.-1 to Ext.-6 as per exhibit list. On the other hand the O.P. did not adduce any evidence to his defense.

Now the point for consideration

Whether the complainant is entitled to get any relief as prayed for ?

::DECISION WITH REASONS::       

At the time of argument the Ld.Lawyer of the complainant submitted that the complainant had submitted the total bill of Rs.1,04,305.20 P(Rupees One Lakh Four Thousand Three Hundred Five and Twenty Paise Only). But the Insurance Company has refused the amount and sanctioned to the tune of Rs.62,385/-(Rupees Sixty Two Thousand Three Hundred Eighty Five Only). Now let us consider whether the Insurance Company lawfully deducted the amount from the total claim of Rs.1,04,305/- (Rupees One Lakh Four Thousand Three Hundred Five & Twenty Paise Only). Now let us consider the Insurance Policy. On perusal of the Insurance Policy it is found that policy was insured in respect of Sourav Agarwala who happens to be the son of the complainant as well as for his daughter Miss Neha Agarwala. On perusal of the policy it is found that sum assured for the son and daughter was Rs.4,00,000/-(Rupees Four Lakh Only)each. On perusal of the policy it is also found that DOM Hospital Limit was Rs.50,000/-(Rupees Fifty Thousand Only). According to the terms and condition of the policy day care treatment means “The medical treatment and /or surgical procedure which is i) Undertaken under General or Local Anaesthesia in a hospital / day care centre in less than 24 hrs. because of technological and ii) which would have otherwise required a hospitalization of more than 24 hours. Treatment normally taken on an outpatient basis is not included in the scope of this definition.

Now let us consider what is day care centre. According to the terms and condition as mentioned in Clause 3.9 “ Day Care centre means any institution established for day care treatment of illness and/or injuries or a medical set-up within a hospital and which has been registered with the local authorities, whichever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under.

                                                          a) Has qualified nursing staff under the employment?

                                                          b) Has qualified Medical Practitioner(s)in charge.

                                                          c) Has a fully equipped operation theater of its  own where surgical procedures carried out

                                                   d)  Maintains daily records of patients and will make these assessable to the Insurance Company’s authorized personnel. ”

 On perusal of the terms and condition day care treatment means any injuries done by any hospital by a recognized medical practitioner. On perusal of the record it is found that ankle surgery was done at Apollo Hospital at Chennai so definitely it is a recognized hospital.

 Now the question comes whether the complainant is entitled to get Rs.1,23,123/-(One Lakh Twenty Three Thousand One Hundred Twenty Three Only). According to the policy for the domestic hospital limit is Rs.50,000/-(Rupees Fifty Thousand Only). According to the policy for the domestic hospital limit is Rs. 50,000/-(Rupees Fifty Thousand Only) So the complainant is entitled to get that amount. Beside that the complainant is entitled to get additional cost of treatment like as dressing, gauze etc.

On perusal of the policy that as per Clause 1.2 Clause A “Room Boarding and Nursing expenses as provided by the Hospital / Nursing Home not exceeding 1%  1 % of the sum insured per day or the actual amount whichever is less. This also includes nursing care, RMO Charges, IV Fluids/ Blood transfusion/ injection administration charges and similar expenses.”

So in the opinion of this Forum the Insurance Authority has rightly calculated the amount to the tune of Rs. 62,385/-(Rupees Sixty Two Thousand Three Hundred Eighty Five Only).

 Next point argued by the Ld.Lawyer of the complainant it is found that in the discharge summary it has been mentioned that date of admission was 14/08/2014 and date of surgery was 15/08/2014 and date of discharge is 26/08/2014. According to the argument of the complainant advanced by his Ld. Lawyer is that the daughter of the complainant was admitted to the nursing home for more than 24 hours as such he is entitled to get the entire amount as claimed. But on perusal of the day care treatment in Clause-2 of Clause 3.10 which states that in the case of hospitalization more than 24 hours it will be treated as a day care treatment even for the argument sake if we hold that the insured was treated more than 24 hours in a nursing home as an indoor patient as per terms and condition of the policy as emphasized in Clause 3.10, the injury in the ankle will be treated as an injury as a day care centre as per Clause 3.9 of the policy.

 So on considering the facts and circumstances it is found that the Insurance Company rightly assesses the compensation to the tune of Rs. 62,350/-(Rupees Sixty Two Thousand Three Fifty Only) as such the complainant is not entitled to get any relief as prayed for.

C.F. Paid is correct.

Hence, ordered that

the case be and the same is dismissed on contest without any cost

Let a copy of this order be given to the parties free of cost on proper application.