Complainant by filing this complaint has prayed for directing the op to pay a sum of Rs.43,770/- and also compensation on the ground he is a bona fide Mediclaim Insurance Policy Holder with Hospitalisation Benefit Policy under the op no.1 for last 12 years by starting the present policy from 1999 and subsequently he renewed the policy and the present policy being No. 030600/48/11/97/003986 is effective from 23.10.2011 to mid night of 22.10.2012 and complainant is not a defaulter in payment of yearly premium.

          During the subsistence of the present policy, complainant suddenly found that all on a sudden his previous Mediguard Policy has been converted to Individual Health Insurance Policy without giving any notice or obtaining any consent from the complainant and on receipt of that complainant raised protest vide his letter dated 02.08.2010 and requested to restore the policy status as before as Mediguard Policy in place of Individual Health Insurance Policy. 

Thereafter complainant submitted objection on 25.10.2010 and requested the op to keep the old pattern policy scheme and by that letter also he lodged a complaint to I.R.D.A. but actually op did not respond.

          After that on 21.10.2010 the complainant sent renewal premium with a further request to renew his policy under Mediguard Scheme as before.  But recently the complainant received his policy for the period of 23.10.2010 to 22.10.2011 and found with utter surprise that the op did not consider the same and did not send the old Mediguard Policy terms and conditions.  Then complainant sent a letter to I.R.D.A. for necessary relief and being disgusted about the conduct of the op, complainant requested the Grievance Cell to take necessary steps on 14.04.2011.  Thereafter he got renewal notice dated 18.10.2011 against Policy No. 030600/48/10/97/000037 from the op wherefrom complainant found that it is noted that both were under Individual Mediclaim Policy but previously same were covered under Mediguard Policy for the period from 23.10.2008 to 22.10.2009 but on renewal it was converted to individual Health Policy for the period from 23.10.2009 to 22.10.2010 and on receipt of the same complainant also sent a letter requesting op for maintaining the old Mediguard Policy.  When both the insured have completed 61 years as on 09.07.2007 but it was not done.  Thereafter he received one letter from General Manager and Assistant General Manager of op from Chennai Head Office in which it was specifically mentioned “that the senior citizens who are our existing policy holders should not be compelled to migrate to new scheme but shall be allowed to continue under the existing Mediclaim Policy and at the time of claim also there should not be any restriction as applicable to the revised scheme but should be proceed as per old terms and conditions only but the op deliberately disobeyed the circular of H.O. of op and thereby clearly acted illegally by denying the principal of natural justice to the present complainant”.  Further the General Manager of op in his circular to all Regional Offices dated 11.08.2008 directed in the manner “please once again take up the matter with the operating offices under your control to examine all the policies renewal after 09.07.2007 and confirm that excess premium refunded as well as balance of claim of payable” but in spite of guide lines of H.O. and I.R.D.A., the op failed to comply that order.

          Further it is submitted that complainant was admitted at Capital Nursing Home (P) Ltd. on 19.03.2012 for his Hernia operation and after the operation he was discharged on 30.03.2012 by the said nursing home, wherein he was asked to deposit a sum of Rs.65,355/- as bill for treatment in the said nursing home.  Accordingly complainant deposited Rs.61,520/- to the said Nursing Home on 30.03.2012 and complainant was discharged on that day after recovery.  Thereafter the complainant submitted claim form dated 12.04.2012 to the op duly filled in and requested to pay the bill of Rs.65,355/- along with all necessary documents.

          On 06.06.2012 complainant at the time of obtaining his Bank Pass Book found that amount of Rs.21,585/- had been paid by the op towards his Mediclaim Policy submitted by the complainant against that claim of Medical bill of Rs.65,355/-.  Accordingly the complainant made protest and also asked the op for reconsidering this bill and to pay the balance amount as per guidelines of I.R.D.A.  But op did not pay any heed and practically such sort of settlement of claim is arbitrary, uncalled for and against principal of natural justice for which the complaint is filed for this case and prayed for payment of balance amount of Rs.43,770/- including compensation etc.

          On the other hand op Insurance Company by filing written statement submitted that actually the cause of action arose in respect of the claim of change of policy status from Individual Health Insurance Policy to Mediguard Policy is not maintainable in view of the fact the said change was made on 23.10.2009 as per verbal request of the complainant.  But thereafter till filing of this complaint in the year 2012 no case was filed so the said case is barred by limitation.  Op therefore submitted his Medicalim Policy was turned down his such prayer.  Considering as per terms and conditions of the policy which was same in the earlier policy or new policy and that settled amount was Rs.21,585/- as full and final settlement of the claim and no doubt from the complainant’s own version he received that amount on 06.06.2012 and in his claim application he noted the Bank account for transferring the same and that was also done.  After acceptance of the claim amount, the complaint is stopped to proceed against the op.

          Further it is submitted that entire claim is uncalled for and for the same should be dismissed.

                                     Decision with reasons

          On proper consideration of the prayer portion of the complaint it is found that complainant has prayed for refund/reimbursement of balance amount of claim only including compensation and that balance amount is Rs.43,770/- on the ground he has already received Rs.21,585/- against that there is no prayer, then how this Forum can consider the submission of the Ld. Lawyer of the complainant to the effect that his present Individual Health Insurance Scheme may be converted to Mediguard Policy and further fact is that change was made in the year 2009 i.e. on 23.10.2009.  Thereafter the policy has converted from Mediguard Policy under the op and thereafter the complainant continued Individual Health Insurance Policy up this stage.  Considering that fact we are convinced to hold that such a claim or relief cannot be granted in favour of the complainant.  But we can say without any hesitation that matter must be decided by the Ombursemen and as per direction of the I.R.D.A. and the present op.  No doubt such sort of prayer if it is considered by this Forum, in that case this Forum has no legal authority to decide because it is already time barred on the ground change of policy status was made by the op invariably on the basis of verbal request of the complainant on 23.10.2009 and whereas the complainant was filed this case on 21.08.2012.  That means on the date of filing, this complaint it was about three years.  But as per provision of law cause of action arose on 23.10.2009 and complaint ought to have been filed by 23.10.2011.  But that had not been done and for which such sort of claim is time barred.

          Now regarding part of payment of the claimed mediclaim amount of Rs.65,355/- we studied minutely the provision of terms and conditions of the policy wherefrom it is found that as per condition of the policy, it is found that in Clause-1.2.1of the Insurance Policy Bond that expenses in respect of hospitalization benefits is limited and restricted to actual expenses incurred or 25% of the insured amount which is less and fact remains in this case, complainant Insurance Policy’s sum insured was Rs.75,000/-.  So, insurance company assessed 25% of Rs.75,000/- adding pre and post hospitalization expenses Rs.2,835/- i.e. total Rs.21,585/-.  So, as per terms and conditions of the policy and also considering the basic restriction and limitation for granting medical expenses in case for Hernia operation as specified in condition 1.2.1 was rightly assessed and that actual amount i.e. Rs.21,585/- was disbursed to the complainant.  No doubt it is out of the total claim of Rs.65,355/- and in this regard we have gone through the ruling report in Civil Appeal No.1557/2004 passed by Hon’ble Supreme Court of India in case “Export Credit Guarantee Corporation of India Ltd. – Vs – M/s Garg Sons International passed on 17.01.2013 (unreported case) wherefrom it is found that the insurer cannot claim anything more than that is covered by the Insurance Policy, the terms of the contract have to be considered strictly without any addition and nature of the contract as the same may be effected the interest of the parties adversely and the contract must be read as a whole and every attempt should be made to harmonize the terms thereof keeping in mind that the rule of contract proferentem does not apply in any case because the terms or clause of the contract is bilateral and is mutually agreed upon by the parties.  Therefore, after considering principle we must have to consider the entire matter in the light of the aforesaid settled legal proposition and also the factual matrics clause as mentioned in the policy because that is valid policy and complainant has relied upon that policy.  Most interesting factor is that complainant has filed his policy marked as Annexure-2 valid period from 23.10.2011 to 22.20.2012 and just on the back page of the policy in clause 1.2.1 it is specifically mentioned that in case of Hernia Operation the complainant shall have to get 25% of the sum insured and that has been paid and also actual expenses incurred of the same and pre and post hospitalization charge payable expenses of hospitalization shall be the actual expenses incurred subject to minimum of 10% of the sum insured and in this case ops have applied this calculation correctly what we have gathered after calculation.  So, considering that fact we are convinced to hold that op acted legally and when the terms and conditions and Clause of the agreement shall be the final, the complainant is also bound by that and for that reason and also relying upon ruling the principle of law as it laid down, we are convinced to hold that practically there is no deficient and negligent service on the part of the op.  But the present complainant without going through his any document that is the insurance policy appeared before this Forum and particularly the complaint was drafted without following the policy bond and document was overlooked and complaint was filed and for which no doubt the complainant has suffered some financial loss.  But for that reason ops are not liable and it is the liability of the complainant and for which we find that this complaint is devoid of any merit for which the case fails.

          Hence, it is

                                          ORDERED

          That the complaint be and the same is dismissed on contest without cost against the contesting op.