Order dictated by:
Sh.Anoop Sharma, Presiding Member
1. Pankaj s/o Shiv Partap Sachar, complainant has brought the instant complaint under section 11, 12 & 14 of the Consumer Protection Act, 1986 on the allegations that complainant has been taking mediclaim policy for himself and for his family for last so many years. In the year 2013 complainant obtained Health Insurance Policy No. 200301/48/13/97/00000162 from opposite party No.1 by making premium of Rs. 6725/- for the period from 24.5.2013 to 23.5.2014. The complainant was suffering from fever and he was to be hospitalized at Sanjeevan Hospital where it was diagnosed that complainant was suffering from (PUD Enteric Fever Hypothrosium) and he remained in hospital w.e.f. 9.3.2014 to 18.3.2014 and incurred an expenditure of Rs. 58,437/- on his treatment. However, the complainant was insured for the amount of Rs. 1,50,000/- plus Rs. 27,250/- as domiciliary Hospitalization. The complainant lodged his claim by submitting all the requisite documents i.e. original bills and report etc. with opposite party No.1 on 21.5.2014. But the opposite party had paid only Rs. 26,554/- and deducted amount of Rs. 31,883/- out of the total claim of Rs. 58,437/- under different heads (Rs.8136/- 36% as per policy terms for (97 code) room rent capping, Rs. 200/- file admission, Rs. 1000/- extra ICU, Rs. 1500/- extra room rent, Rs.4050/- RMO charges, Rs. 3600/- extra nursing charges, Rs. 150/- no report ECG, Rs.10400/- c reactive protein not related to diagnosis, Rs. 1100/- no pres, Rs.131/- easyfix,proline, Rs.950/- no pres, Rs.23/- easy fix, Rs.42/- carefree mouthpaint, Rs.135/- no pres, Rs.331/- no press, Rs.134/- no pres) . The alleged deduction on the part of the opposite parties amounts to unfair trade practice and deficiency in service on their part. The complainant visited the opposite party many a times and requested them to release the balance claim amount and also requested them to provide the documents on the basis of which amount of Rs. 8136/- i.e. 36% was deducted while mentioning code 97 which is not made available to the complainant till date neither the same has been supplied to the complainant at the time of taking the health policy which the opposite party failed to give any satisfactory reply to the complainant The complainant has sought for the following reliefs vide instant complaint:-
- Opposite parties be directed to pay the amount of Rs. 31882/- alongwith interest @ 12% p.a. from 3.7.2014 till date.
- Compensation to the tune of Rs. 30000/- may also be awarded to the complainant;
- Opposite parties be also directed to pay litigation expenses to the tune of Rs. 10000/- .
Hence, this complaint.
2. Upon notice, opposite party No.1 appeared and filed written version in which it was submitted that opposite parties have already paid a sum of Rs. 26,554/- to the complainant in view of the terms and conditions of the Insurance policy. It is pertinent to mention here that as per terms and conditions of Health Insurance Policy-Platinum the liability of company towards room, boarding and nursing exp. was limited as provided by the hospital/nursing home upto 1% of sum insured which also includes nursing care, RMO charges, administration charges and other charges as per policy rule 1.2 (A) and also include extra ICU expenses not exceeding 2% of sum insured per day or actual amount and Rs. 150/- was deducted by opposite party as the complainant had not submitted ECG report but charges of ECG report was included with bill filed by the complainant and Rs. 10400/- was deducted c reactive protein not related to diagnosis and other charges of different categories were deducted as the same were not covered as per terms and conditions of the Insurance policy. It was denied that alleged deduction on the part of the opposite party is illegal. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite party No.2 did not opt to put in appearance despite service, as such it was ordered to be proceeded against ex-parte.
4. In his bid to prove the case complainant tendered into evidence his duly sworn affidavit Ex.C-1, copy of Insurance policy Ex.C-2, copy of claim form Ex.C-3, copy of health Insurance policy Ex.C-4 and closed the evidence.
5. To rebut the aforesaid evidence Sh. Raman Kumar,Adv.counsel for opposite party No.1 tendered into evidence affidavit of Sh.H.K.Prinja , Sr. Divisional Manager Ex.OP1/1, copy of Insurance policy alongwith terms and conditions Ex.OP1/2 and closed the evidence on behalf of opposite party No.1.
6. We have heard the ld.counsel for the parties and have carefully gone through the record on the file.
7. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant has obtained Individual Health Insurance Policy No. 200301/48/13/97/00000162 from opposite party No.1 on payment of premium of Rs. 6725/- covering the period from 24.5.2013 to 23.5.2014. During the subsistence of the policy period, complainant became ill as he was suffering from fever and was to be hospitalized at Sanjeevan Hospital and was diagnosed as suffering from PUD Entreric Fever Hypothrosium and incurred expenditure of Rs. 58,437/- on his treatment. The complainant was insured for the amount of Rs. 1,50,000/- plus Rs. 27,250/- as domiciliary hospitalization. The complainant lodged claim after submitting all the requisite documents i.e. original bills and reports etc with opposite party No.1 as required i.e. on 21.5.2014. But the opposite party had paid only Rs. 26554/- and deducted amount of Rs. 31883/- out of the total claim of Rs. 58,437/- under different heads (Rs.8136/- 36% as per policy terms for (97 code) room rent capping, Rs. 200/- file admission, Rs. 1000/- extra ICU, Rs. 1500/- extra room rent, Rs.4050/- RMO charges, Rs. 3600/- extra nursing charges, Rs. 150/- no report ECG, Rs.10400/- c reactive protein not related to diagnosis, Rs. 1100/- no pres, Rs.131/- easyfix,proline, Rs.950/- no pres, Rs.23/- easy fix, Rs.42/- carefree mouthpaint, Rs.135/- no pres, Rs.331/- no press, Rs.134/- no pres) and the alleged deduction on the part of the opposite parties amounts to deficiency in service. In this regard complainant approached the opposite party and requested them to provide the documents on which amount of Rs. 8136/- was deducted while mentioning code 97 which the opposite party failed to provide . Ld.counsel for the complainant submitted that all this amounts to deficiency in service.
8. Whereas the case of the opposite party is that opposite parties have already paid a sum of Rs. 26554/- to the complainant keeping in view the terms and conditions of the Insurance policy. It was the case of the opposite party that as per terms and conditions of health Insurance policy-Platinum the liability of company towards room, boarding and nursing exp. was limited as provided by the hospital/nursing home upto 1% of sum insured which also includes nursing care, RMO charges administration charges and other charges as per policy rule 1.2 (A) as well as extra ICU expenses not exceeding 2% of sum insured per day or actual amount and Rs. 150/- was deducted by the opposite party as the complainant had not submitted ECG report but charges of ECG report was included with bill and Rs. 10400/- was deducted c reactive protein not related to diagnosis as the same were not covered as per terms and conditions of the impugned Insurance policy. Ld.counsel for the opposite party has vehemently contended that the alleged deduction has been made as per terms and conditions of the Insurance policy and there is no deficiency in service on the part of the opposite party.
9. From the entire above discussion, we have come to the conclusion that complainant has obtained Health Insurance Policy bearing No. 200301/48/13/97/00000162 for sum assured Rs. 1,50,000/- from opposite party No.1 covering the period from 24.5.2013 to 23.5.2014, copy of Insurance policy alongwith terms and conditions accounts for Ex.C-4 on record.. It was the case of the complainant that during subsistence of the impugned Insurance policy, complainant suffered from fever and was to be hospitalized at Sanjeevan Hospital where it was diagnosed that complainant was suffering from (PUD Entreric Fever Hypothrosium) and he remained admitted in the said hospital from 9.3.2014 to 18.3.2014 and incurred an expenditure of Rs. 58,437/- on his treatment. Complainant lodged claim with the opposite party to the tune of Rs. 58,437/- but the opposite party has paid only Rs. 26,554/- and deducted amount of Rs. 31883/- out of the total claim of Rs. 58,437/- under different heads (Rs.8136/- 36% as per policy terms for (97 code) room rent capping, Rs. 200/- file admission, Rs. 1000/- extra ICU, Rs. 1500/- extra room rent, Rs.4050/- RMO charges, Rs. 3600/- extra nursing charges, Rs. 150/- no report ECG, Rs.10400/- c reactive protein not related to diagnosis, Rs. 1100/- no pres, Rs.131/- easyfix,proline, Rs.950/- no pres, Rs.23/- easy fix, Rs.42/- carefree mouthpaint, Rs.135/- no pres, Rs.331/- no press, Rs.134/- no pres). But, however, regarding deduction of Rs. 8136/- i.e. 36% as per policy terms for (97 code), the opposite party has failed to provide the documents i.e. 97 code of the policy terms ,on the basis of which amount of Rs. 8136/- has been deducted . So the said deduction made by the opposite party is illegal and is liable to be set-aside. The remaining deductions have been made as per terms and conditions i.e. liability of company towards room, boarding and nursing expenses was limited i.e. 1% of sum insured which included nursing care, RMO charges, administration charges and other charges as per policy rule 1.2 (A). It was not the case of the complainant that he has not received the terms and conditions of the policy as the complainant himself has placed on record copy of Insurance policy Ex.C-4 which includes terms and conditions of the policy. However,the deduction of Rs. 10400/- has been made on the basis of c reactive protein not related to diagnosis. It was the case of the complainant that he was admitted in the hospital for PUD Entreric Fever hypothrosium and the treatment was given to the complainant as prescribed during hospitalization. But, however, the opposite party has failed to produce any evidence of any doctor to prove that this medicine was not related with the treatment as the opposite party has not produced any doctor to prove that the said medicine was not related with the treatment.
10. So in view of the above discussion, we are of the considered opinion that the deduction of Rs. 8136/- as well as Rs. 10400/- has been made wrongly and illegally. So the complaint deserves to be allowed. The complaint as such is partly allowed accordingly. The opposite parties are directed to pay Rs. 8136/- and Rs. 10400/- in all Rs. 18536/- to the complainant. The opposite parties are also directed to pay litigation expenses to the tune of Rs. 2000/- to the complainant. Compliance of this order be made within a period of 30 days from the date of receipt of copy of this order ; failing which complainant is entitled to get the order enforced through the indulgence of this Forum. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
Dated : 10.4.2017
