O R D E R

 PRESIDENT

1)        By this complaint the Complainant has prayed that the Opposite Party be directed to pay Rs.3,07,576/- being the compensation for deficiency of service and unfair trade practices, as per the provisions of the Consumer Protection Act, 1986 (referred to as the Act).  It is also prayed that the Opposite Party be directed to pay interest @18% p.a. from the deduction of the claim amount till its payment.  It is further prayed that the Opposite Party be directed to pay Rs.15,000/- for mental torture and harassment and cost of Rs.25,000/- towards fess of the Advocate and expenses of this proceeding.

 2)        According to the Complainant he is consumer under the Consumer Protection Act, as the Opposite Party promised to indemnify the Complainant in the event of payment of medical bill for any sickness.  On the said representation the Complainant paid consideration/premium and hired the services of the Opposite Party. It is submitted that the Complainant is retired employee (Development Officer) of the Opposite Party.  He has taken Staff Mediclaim Insurance Policy for himself and for his wife for the sum insured of Rs.3 Lac each. The Opposite Party till filing of the complaint did not issue original policy to the Complainant.  The copy of the premium receipt paid to the Opposite Party is marked as Exh.‘A’. The policy period was 01/04/2010 to 31/03/2011.  The Complainant was admitted in CritiCare Hospital on 15/01/2011. The Opposite Party by its letter dtd.24/06/2011 offered Rs.2,29,253/- against the valid claim of Rs.3,07,576/-.  It is submitted that the Complainant was admitted in the aforesaid hospital for the medical treatment of illness CT Angiography coronary/ angioplasty by Dr. Brain Pinto.  Copies of the medical papers are marked as Exh.‘B’.  It is submitted that the Complainant incurred total expenses of Rs.3,07,576/-.  The copies of bills are marked as Exh.‘C’.  The Complainant intimated the Opposite Party regarding his hospitalization by letter dtd.17/01/2011 and lodged the claim on 27/01/2011. Copies of the letters are marked as Exh.‘D’. The Complainant had written letters dtd.12/03/2011, 10/04/2011, 09/05/2011 to the Opposite Party. The Complainant had also addressed the letter through UNI Customer Department by letter dtd.23/05/2011 but the Opposite Party did not settle the claim of the Complainant.  Copies of the aforesaid letters are marked as Exh.‘E’.  The Opposite Party did not settle the claim of the Complainant and suddenly the Complainant received letter dtd.24/06/2011 on 28/06/2011 alongwith full and final voucher of Rs.2,29,253/-.  The Opposite Party illegally and unlawfully deducted the amount of Rs.78,324/-.  Copy of the letter dtd.24/06/2011 is marked as Exh.‘F’.  It is alleged that the Complainant had not accepted the said amount and asked for the clarification of deduction made arbitrarily by Opposite Party.  It is submitted that retired employee of the Opposite Party are not covered under TPA and the Opposite Party have no right the deduct the claim under GIPSA.  It is submitted that the Complainant had taken the service of CritiCare Hospital which is covered under GIPSA, therefore, the rules of GIPSA are not applicable to the case of the Complainant.  The Complainant did not accept the full and final voucher offered by the Opposite Party and issued notice to the Opposite Party through advocate dtd.18/07/2011.  The Opposite Party did not reply to the said notice.  The copy of the notice issued by the Complainant through advocate is at Exh.‘G’. It is alleged that the action on the part of Opposite Party deducting an amount of Rs.78,324/- is arbitrary which results in miscarriage of justice and it amounts unfair trade practice on the part of the Opposite Patty.  The said action of the Opposite Party is deficiency in service as not discharging promise as per policy.  It is submitted that the reliefs can be claimed u/s.12 of the Consumer Protection Act, 1986 against the Opposite Party.  The Complainant has therefore, prayed to grant the reliefs as per para 1 of this order.

 3)        The Opposite Party contested the claim by fling written version. It is contended that as the Complainant had filed the complaint before Insurance Ombudsman and matter is still pending with Insurance Ombudsman and as such, the complaint is not maintainable. The copies of the documents regarding the proceeding before Insurance Ombudsman are marked as Exh.‘A’.  It is contended that the Complainant was ex-employee of the Opposite Party and is covered under Staff Group Mediclaim Policy for the period 01/04/2010 to 31/03/2011. The claim under the said policy was payable subject to observance of terms, conditions exclusion and expenses reasonably and necessarily incurred for the illness during the hospitalization.  It is admitted that the Complainant was covered for the sum insured of Rs.3 Lacs under the aforesaid policy.  The copy of the said policy is marked as Exh.‘B’.  It is submitted that the documents regarding the claim lodged by the Complainant for the treatment of Coronary Artery disease of Criticare Hospital including hospital dues chemist bills are marked as Exh.‘C’.

 4)        It is contended that the Opposite Party found that the hospital bill for Rs.2,93,969/- for one day hospitalization was on higher side.  The Opposite Party sent letter dtd.28/02/2011 to the Complainant and requested to send the original stamp receipt of Rs.99,000/- for Endeavour Resolute stent and original stamp receipt of Rs.1 Lac for Surgeon’s fees of Dr. Pinto but the Complainant did not sent those original receipts.  The Complainant however sent hospital certificate dtd.11/03/2011 stating that “No item wise separate receipt can be issued”. The copies of the said correspondence are marked as Exh.‘D’.  It is contended that as the Complainant did not send original receipts, the Opposite Party referred the matter to their regional office for approval of claim of the Complainant.  The Opposite Party’s regional office sent letter dtd.25/05/2011 alongwith medical opinion of Dr. Dinanath Vedpathak dtd.09/05/2011 advising to go by the findings of Dr. Vedpathak. The said correspondence is marked as Exh.‘E’.  It is contended that upon going through opinion of Dr. Vedpathak the Opposite Party found that the Complainant’s claim was admissible to the extent of Rs.2,30,700/- against the total claim of Rs.3,07,576/- lodged by the Complainant.  The Opposite Party offered Rs.2,29,252.75 alongwith voucher for signature and returned to the Opposite Party by the Complainant vide its letter dtd.24/06/2011.  The copy of the said letter is at Exh.‘F’.  The Complainant not being satisfied with the amount offered by the Opposite Party sent notice through his advocate to the Opposite Party dtd.18/07/2011.  The copy of which is at Exh.‘G’.  The Opposite Party replied to the said notice through its advocate dtd.08/08/2011 denying the Complainant’s claim as alleged in the notice of the Complainant.  The copy of the said notice is at Exh.‘H’.  It is contended that there is no delay, defect, deficiency or negligence in the services rendered by the Opposite Party. The claim of the Complainant was approved and offered for Rs.2,29,252.75  as per package tariff of CritiCare Multispeciality Hospital for Coronary, Angiogram and for Coronary Angioplasty.  It is contended that the hospital bill issued by the said hospital is in excess of Tariff/GIPSA rates.  The Opposite Party submitted that the Complainant is not entitled to the claim made in the complaint to the tune of Rs.3,07,576/-.  The Complainant has taken insurance of Rs.3 Lac only.  It is denied that the Complainant is entitled for interest as claimed and other amounts claimed by him.  The other allegations made in the complaint are denied by the Opposite Party.  It is contended that the complaint be dismissed with cost.              

 5)          The Complainant has filed affidavit of evidence.  The Opposite Party has filed affidavit of Divisional Manager – D.V. Gajabe.  Both the parties filed documents in support of their contentions. The Complainant has filed written argument.  The Opposite Party has also filed written argument. We heard the argument of Complainant in person and the argument of Shri. J.D. Karanjakar, the Ld.Advocate for the Opposite Party.

 6)        The contention raised by the Opposite Party that at the time of filing of the present complaint the matter was pending before Insurance Ombudsman on the complaint filed by the Complainant and therefore this complaint is not maintainable, in our view cannot be accepted as the Forum under the Consumer Protection Act, 1986 and the Insurance Ombudsman are having different powers.  The aggrieved Complainant even after the decision of Ombudsman has right to file the complaint before the Consumer Forum.   We therefore, hold  that  on  that count it cannot be held that the present complaint is not maintainable.    

 7)        While considering the disputed point raised in the complaint by the Complainant that the deduction of an amount to the tune of Rs.78,324/- on the part of the Opposite Party is justifiable or not, it is necessary to be taken into consideration the Group Mediclaim Policy document which is placed on record by the Opposite Party with its written statement at Exh.‘B’. As per clause 8 of the said policy, it is mentioned that there will be no deduction in the benefit (i.e. sum insured) in the Revised Group Mediclaim Policy for the dependent parents and also the retired employees of 70 years and above as the rating structure is linked to the age. The Complainant was admittedly more than 70 years at the time of the treatment which he had taken from CritiCare Multispecialty Hospital. The said hospital charged the Complainant for the treatment which he had taken in respect of CT Angiography Coronary/Angioplasty to the tune of Rs.2,93,969/-. The Complainant has also produced the bills Rs.13,607/- towards the medicines, external outpatient cash bill payment made to Assian Heart Research Center and to Dr. Pinto and other ancillary expenses incurred for the above treatment.  In our view as per the policy Clause No.8 and other clauses of the policy the deduction made by the Opposite Party is improper and arbitrary.  It is also pertinent to note that in the offer given by the Opposite Party vide its letter dtd.24/06/2011 to accept an amount of Rs.2,29,252.75 by the Complainant, no reasons have been mentioned for the deduction of the amount of Rs.78,324/-. The submissions made by the Ld.Advocate for the Opposite Party that the CritiCare Hospital charged excess amount when there was tariff package rates of the hospital are available for Coronary, Angiography and Angioplasty prepared as per investigation report submitted by Dr. Vedpathak and therefore, the Complainant is not entitled to the claim made in the complaint in our view cannot be accepted as in the policy Cause No.8.  In Clause No.8 there is no mention of such deduction in respect of the retired employee of more than the age of 70 years.  In the similar type of case filed by Renu P. Dalal against the Opposite Party in Complaint No.G1-660 of 2011-12 decided on 25/07/2012 before Insurance Ombudsman the Ombudsman has observed that “Whilst on the issue it is also noted that the Insurance Company has not given reasons for disallowance of balance amount to the Complainant in writing.  In this regard it should be noted that as per IRDA Regulation 2002, Insurance Company in case decides to dispute a claim/portion of a claim, it is there duty to give all the relevant reasons for the same.  It was expected that at the time of settlement of claim, the Company should have given to the Complainant in writing the specific reason for disallowance of the balance amount.”  The Ombudsman in the said case allowed the claim of Rs.53,601/- which was deducted by the Opposite Party in favour of Smt. Renu Dalal who has also filed the claim against the Opposite Party under staff Mediclaim Scheme regarding the treatment provided to her husband Shri. Padmakant Dalal in CritiCare Multispecility Hospital.  In our view in the present case also the similar facts are brought on record by the Complainant.  The contentions raised by the Opposite Party regarding applicability of tariff package as well as the rule of GIPSA in our view is totally improper.  We therefore, hold that the deduction made by the Opposite Party to the tune of Rs.70,748/- against the claim lodged by the Complainant is improper and arbitrary in our view the sum assured regarding the Mediclaim in respect of the Complainant was to the tune of Rs.3 Lacs only and therefore, the Complainant would be entitled to the sum of Rs.3 Lacs only out of claim amount of Rs.3,07,576/-.  The Opposite Party in our view ought to have granted the Mediclaim lodged by the Complainant to the tune of Rs.3 Lacs.  However, as the Opposite Party deducted an amount of Rs.70,748/- from the eligible claim of the Complainant, in our view the Opposite Party has adopted unfair trade practice which amounts to deficiency in service.  As the Opposite Party did not pay the amount of sum insured against the Mediclaim to the tune of Rs.3 Lacs to the Complainant and thereby Complainant has suffered mental torture and harassment.  The Opposite Party is liable to pay compensation to the tune of Rs.8,000/- to the Complainant.  The Opposite Party is also liable to pay interest @ 6% on the amount of Rs3 Lacs from 24/06/2011 till its realization to the Complainant.  The Opposite Party is also liable to pay cost of Rs.10,000/- towards the advocate fess and for this proceeding to the Complainant.  In the result the following order is passed –

O R D E R

i.                    Complaint No.260/2011 is partly allowed against the Opposite Party.

ii.                 The Opposite Party is directed to pay an amount of Rs.3,00,000-(Rs.Three Lacs Only) to the Complainant alongwith interest @ 6% p.a. from 24/06/2011 till its actual payment.

iii.               The Opposite Party is directed to pay an amount of Rs.8,000/-(Rs.Eight Thousand Only) as compensation to the Complainant towards the mental torture and harassment.

iv.               The Opposite Party is directed to pay cost of Rs.10,000/-(Rs.Ten Thousand Only) towards this proceeding to the Complainant.

v.                  The Opposite Party is directed to comply the aforesaid order within one month from the date of receipt of this order.

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