JUDGEMENT Complainant by filing this complaint has submitted that they purchased Individual Mediclaim Renewal Policy No.030900/48/11/20/00000121 from the op no.1 in which they were insured having validity of the said policy was from 12.05.2011 to midnight of 11.05.2012 and complainant pain an amount of premium of Rs.10,479/-. Subsequently complainant no.2 Gayatri Mitra suffered from cataract problem in her right eye. So, she had to undergo operation and her right eye was operated on 24.03.2012 at Sankara Nethralaya, Kolkata-147 and for which complainant no.1 paid a sum of Rs.42,673/-. Complainant no.1 intimated the fact of operation of his wife to the op no.2 and TPA received the said notice on 22.03.2012 and that information was also received by the op no.1. But TPA Heritage Health TPA Pvt. Ltd. op no.2 vide a letter dated 11.05.2012 settled the claim of complainant in full and final settlement by providing through transfer an amount of Rs.15,512/- and the complainant received the said amount of Rs.15,512/-. On protest and lodged protest to the op no.1 vide notice dated 06.06.2012. Thereafter correspondences took place between the complainants and the ops. Subsequently op no.2 vide letter dated 24.07.2012 settled the claim in full and final settlement by providing through transfer amount of Rs.5,000/- and more. Thereafter complainant claimed balance amount of Rs.22,161/- but they did not provide it and claim was not fully satisfied and for which for adopting unfair trade practice and for not giving proper service, complainant has filed this complaint for redressal. On the other hand op by filing written statement submitted that the said application is not maintainable because there was no negligence and deficiency on the part of the op because the matter that is the claim of the complainants had been duly settled and complainants received such amount already. But further complainant submitted that during subsistence of the relevant policy, the PPN System of disbursement of claim for individual category of diseases was fixed by the IRDA, an Organ of the Ministry of Finance, the Govt. of India and the introduction of PPN was made irrespective of policy effective date and it was communicated to the general public through all print Media on 16.01.2012 making it as constructive notice. It was inter-alia by such PPN notification communicated to the general public as a whole that in the event of any occurrence of claim, the guideline as set forth in the said PPN System would be followed while settling the claim and the concerned network hospitals and the TPAs where informed accordingly for fixing cost of treatment of each category diseases at affordable price for the general insuring people. It is further submitted that the hospital where the complainant’s wife was treated was also aware about such introduction of PPN System. However it appears that the complainant avoided to communicate with the relevant hospital regarding the existence of their mediclaim policy and as such no communication was divulged accordingly to the hospital and for such reason the said hospital could not have any opportunity so as to inform the complainants about such introduction of PPN System and strangely enough that the complainants preferred a TPA policy but surprisingly complainants choose not to intimate the claim to the named TPA in his policy and accordingly submitted the claim documents not to the TPA but to the insurer directly in aberration to the standard norm of the relevant policy. Admittedly within the purview and scope of the relevant policy, the TPA disbursed a total sum of Rs.20,512/- against the total claim of the complainant of Rs.42,673/- and thus as per complainant the remainder of alleged claim amount of Rs.22,161/- was left to be redressed and this is the capsulated factual matrix of the entire claim case. It is further submitted that introduction of PPN System is in fact a packaged System floated by the GIPSA (a parent body of four nationalized Insurance Companies) so that a general cost of premium can be set for the people for insuring large number of public with affordability and it cannot be construed as alleged capping system or at all. Further it is submitted that the TPA and ops after considering the said PPN System as already introduced after considering the total claim as per guideline of IRDA disbursed the total sum of Rs.20,512/- and no further claim can be settled by the ops and that was reported to the complainants. So under any circumstances complainant subsequent claim of Rs.22,161/- is not tenable in the eye of law in which the complaint should be dismissed when there was no deficiency and negligence on the part of the op. Decision with reasons After thorough study of the complaint and written version including the argument as advanced by the Ld. Lawyers of both the parties, it is clear that complainants are Mediclaim Insurance Policy holder and fact remains the complainant no.1’s wife underwent an operation in her right eye for cataract and for that purpose she was admitted to Sankara Nethralaya, Kolkata where operation was done and at the relevant time both were aware of the fact that they are entitled to get such benefit by reporting the matter to TPA. But fact remains complainant did not disclose that they are Mediclaim Policy holder and if it would be submitted before the Sankara Nethralaya authority, at the time of operation, in that case complainant shall have to get this amount as has already been released by the op as per guideline of IRDA that is PPN System and PPN System was introduced as per order of IRDA and that was published in all Media and newspapers on 16.01.2012 making it as constructive notice and it was a general notification communicated to the general public as a whole and that PPN System was introduced during pendency of the present policy. But as per order of IRDA, it is applicable to all policies irrespective of their policy inception as on 16.01.2012. When that is the fact then it is clear that in respect of the present policy, PPN System is clearly applicable legally and complainant cannot anyway challenge that PPN System as PPN System is not applicable in respect of his policy because all the Insurance Companies are guided by IRDA and if there was any allegation of the complainants about introduction of PPN System, complainants ought to have filed such allegation before the IRDA authority if IRDA shall not give any special protection to the complainants in that case complainants are not entitled to get any relief in the present complaint because the Insurance Companies are guided by the Rules and System as introduced by IRDA and admittedly the said system was introduced and it is applicable in respect of all pending Insurance Mediclaim Policies. Another factor is that the operation was already on 24.03.2012 and policy was valid from 12.05.2011 to 11.05.2012 whereas PPN System came into operation with retrospective effect and practically the present policy was initiated on and from 12.05.2011 and prior to end of said policy, the PPN System was introduced. So, PPN System is applicable in the case of present complaint also and no doubt op as applied that PPN System in the present policy and released Rs.20,512/- but complainant have already received. Considering the above fact and also the terms and conditions of the policy and the IRDA guidelines by which complainant realized that amount so we are convinced to hold that this Forum cannot decide against the direction of the IRDA when IRDA is a controlling authority or Commission of all the Insurance Companies and in the present case, op has pointed out that fact and that is the legal position in the present policy and also for which we are convinced to hold that under any circumstances op Insurance Company has any legal authority to release further amount because complainant and his wife is entitled to said amount that is Rs.20,512/- as per PPN System and that was implemented during continuation of the policy. So, we are convinced to hold that there was no legality arbitrary act on the part of the op and on the contrary there was no deficiency and negligence on the part of the op because -------------- decided the matter forthwith and released that amount and complainant received the same. In that case Ld. Lawyer for the complainant has tried to say that PPN System came into force after lapse of 8 months from the date of inception of the policy. But considering the order of PPN System we have gathered that PPN System is equally applicable in respect of all pending insurance Mediclaim Policy and it is always retrospective not perspective. So, we find that the Ld. Lawyer for the complainant was misconceived about that and tried to say that once a Mediclaim policy is opened and when PPN System was not existence at that time. PPN System subsequently introduced cannot be tagged with the present policy. But legal interpretation is very much in favour of the op and law is that PPN System is applicable in respect of the pending insurance policy also. So, PPN System is equally applicable in the case of the complainant. But we have gathered that complainant did not report the matter of holding a Mediclaim Policy to Sankara Nethralaya at the time of admission and it was done with intention because it is the rules of law that any Medicalim Policy holder must have to report to the hospital authority in which he or any insured has been admitted for operation and in that case complainant did not report it intentionally because they realized that if they shall have to report their Mediclaim Policy matter in that case they shall have to get such amount as per PPN System and to avoid it the complainant did not report it to the TPA or also not to the hospital authority at the time of admission for cataract operation. No doubt it has become a practice to somehow release the entire Mediclaim Policy they are not in a position to obey the rules as applied by IRDA and its implementation for which if PPN System cannot do it and if complainant is dissatisfied of the order of IRDA, they may challenge at Hon’ble High Court or IRDA not before the Forum and Forum has no authority to declare IRDA’s order and notification as invalid and if complainant wants to get any relief against IRDA such notification complainant may proceed to Civil Court or to High Court. In the result, the complaint fails. Hence, it is ORDERED That the complaint be and the same is dismissed on contest against the ops but without any cost.
| | [HON'ABLE MR. Ashok Kumar Chanda] MEMBER[HON'ABLE MR. Bipin Muhopadhyay] PRESIDENT[HON'ABLE MRS. Sangita Paul] MEMBER | | 
