This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted that complainant purchased one Mediclaim Policy being No.030300/48/10/97/00008714 having validity from 26-03-2011 to 21^st March, 2012, midnight and complainant is covered under the policy and its Gold Policy Premium was Rs.7,592/- and sum insured is Rs.2,50,000/-.

          During validity of the said policy complainant was admitted to ILS Hospitals with severe spasmodic pain in abdomen specially in right hypochondrium as per advice of the doctor for investigation and treatment and the ultrasound report showed acute calculus cholecystitis and so placed under the supervision of Dr. Om Tantia for further management and treatment.  Thereafter, the laparoscopic cholecystectomy was done by Dr. Om Tantia under anesthesia under cardiac monitoring and the complainant was hospitalized in the said hospital from 14-11-2012 to 17-11-2011 and on the day of discharge ILS Hospitals’ bill was Rs.76,070/-.  Complainant after returning from hospital submitted his claim with all documents required for settlement of the aforesaid claim as per direction of the OPs within the specified time in order to seek reimbursement of the medical expenses and the cost of hospitalization incurred during such hospitalization but on 24-02-2012 complainant received a letter from the Heritage Health TPA Pvt. Ltd. a full and final settlement of the complainant’s claim of Rs.76,417/- and by disbursing only a sum of Rs.44,120/- as full and final settlement of the claim.  Against that complainant wrote an objection on the ground of realizing certain amount out of total claim and complainant against that received a letter from OP4 to the effect that there was no ground for releasing any further amount as it was decided on merit and Rs.44,120/- was disbursed as full and final settlement.  That complainant raised claim as per sum assured and the claim as per Clause 1.2 but OP without any ground did not allow the entire claim for which complainant appeared before this Forum for releasing balance amount of Rs.32,297/- together with interest @18% p.a. etc. and other charges for compensation.

          On the other hand, OP by filing written statement submitted that TPA disposed of the matter on 24-02-2012 and intimated to the complainant and then replied and have categorically clarified the disputes raised by the insured to the tune that although the number of bed where the insured was admitted having no nomenclature that whether it is a general bed or an ICU as claimed by the insured together with the fact that the admission took place on 14-01-2011 at 01.58 hours at bed NO.107 but ITU charges not ICU was levied by the hospital from 13-11-2011 for the whole day and further as per treatment sheet, despite doctor advised for shifting the patient in other bed on 15-11-2011 but not changes in the occupancy was made as available from the bed charges of the hospital dated 15^th, 16^th and 17^th November, 2011 and TPA decided it reasonable in considering the entitlement of bed category (without nomenclature) against settlement of claim under the subject policy and all other expense have also been apportioned to the entitlement of the bed category @Rs.2,500/- per day as per policy terms, Clause 1.2.  In this regard further it is submitted that the Individual Health Insurance Policy, 2009 is to be differentiated and distinguished from Health Insurance Policy- Gold and as much the terms and conditions as attached thereto are also not identical and hence, this OP relies on the terms and conditions as annexed with the Individual Health Insurance Policy – 2009 only and accordingly, OP decided this claim and settled the claim of the complainant and finally released Rs.44,120/-.  So, considering the entire materials the matter was decided applying everything with the scope of the policies and fact remains the complainant is not entitled to the sum of Rs.5 lakhs on the score of mental agony, pain and suffering etc. and is also not entitled to other amounts for deficiency in service, litigation cost etc.  At the same time the complainant has already received the said amount of Rs.44,120/- and there is no ground for reconsidering the same when the balance amount cannot be released in view of the clause of the said policy and there was no fault on the part of the OP and there is no negligence and deficiency on the part of the OP for which the complaint should be dismissed.

Decision with Reasons

On careful and meticulous study of the entire compliant and written version it is undisputed fact that complainant is a mediclaim policy holder of Health Insurance Policy Gold and terms and condition of the Health Insurance Policy, 2009 is valid by the OP for settlement of the claim in respect of mediclaim for a sum of Rs.76,417/- and no doubt TPA after considering all the factors released a total sum of Rs.44,120/- as settled amount as full and final settlement by the letter dated 24-02-2012 and it is undisputed fact TPA also issued full and final settlement of the claim of the said mediclaim vide their letter dated 24-02-2012 and that is annexed in the written version Annexure – G page 88.  Truth is that Ld. Lawyer for the complainant submitted when the bill was submitted by the complainant after receipt of the same by ILS, there was no scope for TPA to deduct any amount when the bill was prepared by ILS Hospital and so, the deduction out of total claim by the OP is illegal but after considering the full and final settlement order of the TPA it is found that patient was admitted to ILS and no doubt details of deduction was made by the TPA mentioning the perfect clause in detail and in the said detail of deduction OP pointed out the reasons for deduction because as per entitlement of room charge the fees of the doctors and other matters shall be guided and that is the settled position and that is specifically mentioned in the clause.  Fact remains in the discharge certificate it is mentioned what type of room the patient was allowed and, in fact, there was no ground for keeping the patient in any other special bed when there is no such advice of the doctor in the discharge certificate and accordingly, the OP fixed room rent Rs.2,500/- of four days i.e. total Rs.10,000/- and that is also assessed as per clause i.e. 1% of the sum assured.  So, apparently there is no illegality for assessing room charge for four days Rs.10,000/- when as per agreement clause of the policy 2/1 a b c d etc. it is clear that deduction against different bill are properly assessed.  So, as per entitlement of room category that is Clause 1.2 fact remains OP in detail noted against all the bill regarding details of deduction and after deduction the final bill was settled to the extent of Rs.44,120/- and in the said bill it is also specifically mentioned acceptance of the above payment shall mean your acceptance of full and final payment against above claim and your according to subrogate both of us and the insurer from further claim and liabilities etc. and admitted fact is that the OP has received the said amount.  So, considering the said letter and receipt of the same no doubt complainant has not initially raised objection of settlement amount by refusing to accept the same.

          Moreover, to get the balance amount of entire claim complainants subsequently procured one certificate from the doctor of the Hospital to prove that doctor placed the patient to higher class of bed for proper treatment of the patient but if actually we rely upon the said letter of doctor of ILS in that case it must be said that the said letter was issued by the doctor of the ILS as per request of the complainant because in the treatment sheet or discharge summary there is no whisper that the doctor advised the patient for keeping him or her in special bed.  So, considering the fact we are convinced to hold that such a letter issued by the doctor was not justified if actually doctor advised for placement of the complainant for some special category of bed after consulting such situation then it would be reflected in the treatment sheet but most interesting factor is that same is not found so TPA invariably considered pros and cons of the bills including the reasons for determination and settlement of such an amount as final settlement. 

          Not only that the TPA also reported to the complainant in details the ground for such rejection and for not considering the subsequent note of the doctor and that detail was submitted by the TPA on 19-06-2013 and complainant also received the same.

          From facts and circumstances of the entire materials on record we hve gathered that TPA or the OP rightly deducted such portion out of the total bill after considering all the clauses and terms and condition of the policy and no doubt about calculation of deduction there is no defect when we have gathered that same has been done after complying the terms and condition of the policy.  At the same time after applying our judicial mind and conscience we have gathered that mediclaim policy holder must be guided by the terms and condition of the policy and that is the mandate of the National Commission also and in so many judgment National Commission has observed that the insured and insurer shall be guided by terms and condition of the policy and there is no question of any relaxation on the ground of equity and in this regard we have relied upon one ruling reported in 2013 (4) CPR 165 NC and not only that after considering the policy conditions also we have gathered that the final settlement as made by the OP is justified as same was done on the basis of the terms and conditions of the policy and when complainant already received the said amount then there is no deficiency and negligence on the part of the OP.   In the light of the above observation we are convinced to hold that the present complaint bears no merit in respect of allegations of deficiency and negligence on the part of the OP when assessment was made as per terms and condition of the policy.

          No doubt complainant has tried to increase the amount for getting more money as per bill of the hospital but it is impossible to accept such grievance of the complainant in view of the fact that the doctor on 23-03-2012 issued such certificate when complainant already received the full and final settlement of the bill from the OP.  So, the subsequent matter cannot be anyway taken into account by any authority when same was not advised during the existence of the patient in the hospital.

In the result, the complaint fails.

Hence,

Ordered

That the case be and the same is dismissed on contest against the OPs without any cost.