Order-17.
Date-04/08/2015.
Complainant Syamal Ganguli by filing this complaint has submitted that on or about 22.11.2001 complainant purchased a Mediclaim Policy of United India Insurance Co. and there was a provision for renewal of the same yearly and as per terms and conditions as disclosed by the op the said policy was purchased and accordingly complainant renewed his policy up to 2011-12.
Subsequently complainant discovered that the original terms and conditions of the policy have been varied from time to time. But as per provision of law, op cannot vary the terms and conditions unilaterally without a notice and/or consent or knowledge of the complainant and deviation in the renewed policy from the original policy is void. So, subsequent changed terms and conditions of the policy is not binding upon the complainant and complainant preferred a claim on 24.01.2012 and claim was Rs. 1,27,440/- against that complainant received an unsigned communication from the op in the year 2012 and complainant clarified the same by his letter dated 20.06.2012 and in fact complainant was suffering from C.A. Lung and is under continuous treatment ever since then and is not required to be admitted to the Hospital and as per terms and conditions of the policy he is entitled to reimbursement and accordingly complainant was admitted, treated but most peculiar factor is that op did not release any payment against the claim and rejected the claim after lapse of time. However during subsistence of the said policy on 09.09.2012, practically complainant was admitted to R.S.V. Hospital and was suffering from Pneumothorax and due intimation of such admission reported to the op by the complainant.
Thereafter complainant after treatment was released on 13.09.2012 and submitted his claim of Rs. 87,628.77 paisa on 20.09.2012. On 16.11.2012 op remitted a sum of Rs. 62,461/- through ECS to the complainant’s Bank Account in SBI, Vivekananda Branch. Complainant also claimed on 28.11.2012 a post-hospitalisation claim for Rs. 70,849/- after his release from the hospital and on enquiries it appeared that the op declined to entertain the claim and nothing had been communicated to complainant. But as per terms and conditions of any claim should be decided within 30 days but that has not been done. But as because there was Arbitration Clause and complainant filed an application before the Hon’ble High Court, Calcutta for relief of Arbitration and Conciliation Act, 1996, Hon’ble Justice Sanjib Banerjee passed an order in this case stated that the arbitration clause may not execute as the part payment has to be done by the op and in the above circumstances for the negligent and deficient manner of service, complainant filed this complaint claiming outstanding dues of Rs. 1,12,539/- and interest over the same that the accumulated amount is Rs. 36,104/- and other relief against the op for op’s negligent and deficient manner of service.
On the other hand op Insurance Company by filing written statement that no doubt complainant purchased the said policy and terms and conditions of the relevant Individual Health Insurance Policy clearly specified what extends the Insurance Company would be liable to pay in case of claim and the complainant has full knowledge of the same and that contract is binding upon both the parties.
As per Clause 1.2 of the policy stipulates that if any claim is admissible, the insurance company will pay through TPA to the concerned hospital/nursing home or the person, the amount of such expenses falling under different heads but not exceeding the sum insured and regarding pre and post hospitalization expenses Clause 1.3 is applicable where it is stipulated expenses payable in respect of each hospitalization shall be actual expenses, subject to Maximum 10 percent of S.I., whichever is less and in regard to expenses incurred for ICCU stay is being 2 percent of S.I. per day as per Clause 1.2B and op has further submitted that certain expenses are fully excluded of the policy terms and conditions Clause 4.20 and 4.21 of the policies for the year 2009-10, 2010-11 and relevant policy 2011-12.
During the policy period 22.11.2010 to 21.11.2011 S.I. was Rs. 1,75,000/- and the complainant admitted to the hospital on 23.04.2011 and released on 14.06.2011 for which a claim of Rs. 1,59,965/- was lodged and after necessary deduction as per policy condition a sum of Rs. 1,48,515/- was paid to the complainant on 22.09.2011 as full and final settlement of the claim, but no objection was raised by the complainant against op.
It is further submitted that in the policy period 22.11.2011 to 22.11.2012 three nos. of claims were put into action i.e. on 24.01.2012 of Rs. 1,27,424/- and on 09.09.2012 of Rs. 87,628/- and on 28.11.2012 of Rs. 70,849/-. All that claim though barred by limitation at present but the complainant for the better understanding of this Ld. Forum submits that the claim dated 24.01.2012 is not relating to hospitalization or post hospitalization and are not payable as per policy condition and it is related to purported medical expenses as an outdoor patient, which is not covered under policy condition No. 1.1, the Clause 1.2 A,B,C,D and E specified heads under which expenses incurred are payable and it is specifically stated in the Note:2 and no payment shall be made under 1.2C other than as part of the hospitalization bill.
The terms and conditions of the policy is clear in this respect that post hospitalization stretching upto 60 days of discharge is payable. In this case no such hospitalization had taken effect and it is admitted by the complainant by his letter dated 25.04.2012 that no such hospitalization had taken effect during the claim period or it is not a fact that the expenses had taken place within 60 days from the date of discharge. Oral chemotherapy is an outdoor procedure and not payable as per policy terms and accordingly the TPA informed the same to the complainant.
According to policy terms the complainant entitled to 10 percent of the S.I. (Condition No. 1.2B) i.e. Rs. 1,750/- per day for 4 days +Rs. 7,000/- being paid to the complainant deducting Rs. 1,200/- for his claim Rs. 8,200/- and other bills for that period are not payable as per policy condition No. 1.2B, 4.16, 4.20, 4.21. Complainant submitted 4 nos. of bills for medicines dated 27.08.2012, 15.09.2012, 16.09.2012 and 20.09.2012 for Rs. 34,354/- together with his second claim and as per policy condition pre and post hospitalization expenses limited to 10 percent of S.I. Rs. 1,75,000/- i.e. Rs. 17,500/-, accordingly the said sum was paid to the complainant deducting Rs. 16,855/-.
It is not necessary to explain why the amount of Rs. 62,461/- being paid to the complainant for his second claim since it is hopeless barred by limitation as prescribed in C.P. Act but for understanding of this Ld. Forum it is submitted after deducting Rs. 25,168/- as per condition out of total claim of Rs. 87,629/- and credited to his bank account and after receiving the amount of Rs. 62,461/- the complainant raised third claim on 19.11.2012 for Rs. 70,489/- for medicines during the period 25.09.2012 to 09.11.2012 and the post medical expenses maximum allowed is Rs. 17,500/- within 60 days from the date of release was paid under claim no. and there was no record of hospitalization after 2nd claim, no further bills for medicines are payable and for the above reasons that no hospitalization had taken place after the 2nd claim the purported claim for the third time for Rs. 70,489/- is not payable as per policy condition and this are also barred by limitation.
It is specifically mentioned that policy for each year is a separate contract and the complainant was bound by the terms of the said contract and if dissatisfied he has liberty to quit. But the complainant did not raise any objection at the relevant time of purchase of Mediclaim Policy year after year and in fact only for grabbing money, this false complaint is filed only to harass the op.
Decision with reasons
On proper consideration of the complaint and written version and also considering the policy conditions, it is clear that policy conditions are renewable as per Regulation of the IRDA and also as per order of the Finance Department (Insurance Government of India).
Truth is that complainant purchased policy along with policy condition knowing fully well the terms and conditions when it is yearly valid policy, so the terms and conditions attach with the policy is binding upon the complainant in this regard complainant cannot raise any objection and another factor is that this Forum has no jurisdiction to decide what type of terms and conditions they introduced per year. If there is any allegation in this regard, complainant may file a writ petition before the Hon’ble High Court for declaration that said terms and conditions as ultra vires. But the allegation in this regard as made by the complainant is found completely uncalled for before this Forum.
Next question is whether complainant is entitled to such claim as made by the complainant for balance dues as against three claims. In this regard we have gathered that three claims were made by the complainant on 19.11.2012 and Rs. 70,489/- for medicines was made during the period from 25.09.2012 to 09.11.2012. In this regard it is found that prior to such claim, complainant was not hospitalized after second claim and as per Note.2 of the policy against condition No. 1.1 and Clause 1.2 A,B,C,D & E no payment shall be made under Clause 1.2C other than as part of the hospitalization bill.
But in respect of the third claim, there was no question of hospitalization. It is admitted by the complainant. Moreover as per terms and conditions of the policy, it is clear that post hospitalization stretching upto 60 days of discharge is payable but in this case no such hospitalization had taken place and it is admitted by the complainant by his letter dated 25.04.2012 that no such hospitalization had taken effect during the claim period and the expenses had taken place within 60 days from the date of discharge. Moreover oral chemotherapy is an outdoor procedure and not payable as per policy terms and no doubt in this regard TPA informed the same to the complainant.
So considering the entire fact, claim of the complainant in respect of the third claim made on 19.11.2012 for Rs. 70,489/- was rightly rejected by the ops. No doubt for post medical expenses maximum limit is Rs. 17,500/- within 60 days from the date of release that paid under claim but no further claim was considered as there was no record of hospitalization for second claim.
Against claim of Rs. 87,629/-, Rs. 62,461/- was paid but out of that Rs. 25,161/- was deducted and balance was credited to the complainant’s bank account and that was paid as per policy condition what we have gathered. It is also found that complainant was admitted to hospital on 23.04.2011 and released on 14.06.2011 for which claim of Rs. 1,59,965/- was lodged and after necessary deduction as per policy condition a sum of Rs. 1,48,515/- was paid to the complainant on 22.09.2011 as full and final settlement of the claim and further Rs. 17,500/- was paid to the complainant.
After proper consideration of the entire materials on record, it is found that the claim dated 24.01.2012 is not related to pre-hospitalization or post hospitalization. So, same are not at all payable as per terms and conditions of the policy as noted against condition No. 1.1. In fact sum insured is Rs. 1,75,000/-. So, the payment shall be made as per terms and conditions of the policy and anyway the claim shall not exceed the said sum insured and also the claim shall be related to hospitalization and pre and post hospitalization expenses and in respect of pre and post hospitalization expenses limit is 10 percent always out of the total sum insured and for which bills for medicines dated 27.08.2012, 15.09.2012, 16.09.2012 and 20.09.2012 for Rs. 34,354/- together with his second claim and as per policy condition pre and post hospitalization expenses limited to the extent of Rs. 17,500/- was paid and in this regard we find that op properly calculated the same which is admissible as per terms and conditions of the policy.
In view of the above fact and circumstances, we find that all the claims were properly decided by applying judicial mind and also applying the terms and conditions of the policy and in fact we have failed to search out any deficiency, negligence on the part of the op and in all cases admittedly op disposed of those claims of the complainant and remitted the amount to the complainant and complainant has admitted that he received those amount. But his claim is for the balance deducted amount to be paid by the op. But we have gathered that the claim of the complainant is completely baseless and without any foundation and there is no legal ground to consider the claim of the complainant because complainant is not entitled to entire claim as per terms and conditions of the policy as already discussed .
In the light of the above observation we are convinced to hold that in fact complainant wants to remove all the conditions of the policy and to get the entire amount, but there is no scope to declare any terms and conditions of the policy as void and no doubt in the present case after comparative study of the claim of the complainant with the version of the op and relying upon the terms and conditions of the policy, we are convinced to hold that no Arbitrary Act was done by the ops, but ops with on proper judicial mind discussed all the claim application and admissible amount has been paid. So, there is no question releasing any further money on the ground of equity also. In fact it is an attempt on the part of the op to collect the said balance amount anyhow by convincing the Forum all the terms and conditions is illegal, void etc. But the Forum is not established for giving relief in this regard in respect of the complainant’s prayer on the ground Forum is here and there for deciding any defect and deficiency but Forum has no civil Court power to declare any terms and conditions as void.
So, the entire complaint is baseless and without any foundation. But we have gathered that greedy consumers are in the field for getting relief in such a manner for which this complaint fails.
Hence, it is
ORDERED
That the complaint be and the same is dismissed on contest without any cost against the op.
