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

          Complainant Anil Kumar Jalan a bona fide Mediclaim policy Holder of the OP/Insurance Company, United India Insurance Co. Ltd. vide policy no.030300/48/12/97/00000565 for the period from 25-04-2012 to 24-04-2013 and the policy was for himself, his spouse and family members for a sum assured of Rs.1,50,000/- each and premium was paid Rs.21,544/- and the said policy was continued and for the period from 25-04-2012 to 24-04-2013 it was also valid.

          Practically, Apurba Jalan, the son of the complainant had been admitted in Belle Vue Clinic on 25-11-2012 as per Doctor’s advice for necessary treatment of fracture on his right hand little finger and accordingly the matter was also informed to the OP vide its letter dated 26-11-2012.  The complainant incurred total medical expenditure for treatment of his son Apurva Jalan amounting to Rs.1,06,368/- including the cost of hospitalization and submitted before the OP for re-imbursement of the same.  

          The specific case of the complainant is that after discharge of his son Apurba Jalan from the Belle Vue Clinic, the complainant submitted the duly filled up claim form on 14-01-2013 which was received by the OP, but they took decision arbitrarily and in an unlawful manner and the OP wanted to release only Rs.40,968/- out of the total incurred expenses of Rs.1,06,368/- for such medical treatment of his son.  Though the complainant requested the OP/Insurance Company vide its letter dated 14-01-2013 to pay the claim in full but the OP did not pay any heed in the matter.  Hence, this case.

          On the contrary the OP by filing written objection submitted that the complainant’s petition is not maintainable in the eye of law and subject matter of dispute raised by the complainant in the entire case has no cause of action and in view of the fact the present complaint is barred by limitation under provision of C.P. Act, 1986.

          OP has asserted that they had informed the complainant vide its letter dated 08-03-2013 that his claim has been approved for Rs.40,968/- taking into consideration of policy condition No.1.2A i.e. clubbing of room rent etc. and accordingly settlement intimation voucher was sent to the insured/complainant being enclosed with the said letter with a request to return the same so as to enable them for payment under NEFT system.  It is also stated by the OP that no decision was taken arbitrarily and in unlawful manner without going through the rules and clause and procedures as alleged by the complainant.  Further it is also stated that there is no relevance as compared with the certificate dated 11-01-2013 as submitted by the complainant and issued by the Belle Vue Clinic about the mode of settlement as it was followed entirely at the basis of the terms and conditions of the policy.  Fact remains that the claim has been settled by the OP which was duly informed to the complainant vide letter dated 08-03-2013 i.e. within a very reasonable time after due application of mind, then it does not constitute any deficiency in service on its part so the complainant is not entitled to relief or reliefs as prayed for.

Decision with Reasons

All the points are taken up together for consideration and for the sake of convenience and brevity.

          The OP has admitted that the son of the complainant/Insured was admitted at the Belle Vue Clinic on 25-11-2012 as per doctor’s advice for necessary treatment of fracture on his right hand little finger and was under the treatment for two days.  The complainant asked for reimbursement a sum of Rs.1,06,368/- towards the treatment of the son of the complainant being one of the insured and the claim was preferred and the same has been settled by the OP for Rs.40,968/- taking into consideration of policy condition no.1.2A i.e. including room rent etc. and accordingly settlement intimation voucher was sent to the insured/complainant with a request to return the same as to enable them for payment under NEFT system.  The OP strongly denied also that the decision was taken arbitrarily and in an unlawful manner in settlement of claim without going through the rules and procedures of concerned hospital as alleged by the complainant.  Fact remains that the certificate dated 11-01-2013 issued by the Belle Vue Clinic has got no relevance with the mode of settlement as alleged because the insurance company had to follow entirely the terms and conditions of the policy while settling the claim of the complainant.  so, the OP/Insurance Company settled the amount of Rs.6,927/- only on account of pre and post hospitalization and Rs.34,040-61 paisa has been assessed on account of cost of treatment for the insured.

          The OP’s main contention is that the amount of Rs.1,06,368/- which has been claimed by the complainant in this case is arbitrary motivated and for wrongful gain when same is beyond the terms and conditions of the policy when it is a settled principle of law that parties to the contract of insurance are bound by the terms and conditions of the policy and also referred two judgments i.e. 2011(2) CPR 173 N.C. and 2010 (4) CPR 35 N.C. in support of their submission.

          Now, the crux of this case is whether the complainant is entitled to get relief as prayed for and whether there is any deficiency on the part of the OP/Insurance Company who did not pay/reimburse the total claim as submitted by the complainant.

          We have considered the contention of both the parties.  Admittedly the insured son of the complainant was admitted in Belle Vue Clinic on 25-11-2012 on Doctor’s advice for treatment of fracture on his right hand little finger at Belle Vue Clinic and had been covered under the Mediclaim Policy.  As per the Belle Vue Clinic’s receipt Rs.93,066/- was incurred during the hospitalization of the insured and the OP/Insurance Company only approved for Rs.40,968/- taking into consideration of policy condition No.1.2A i.e. adjusting all fees as per policy for reimbursement out of total expenses as claimed by the complainant.

          The moot question is whether the release of fund by the OP/Insurance Company to the tune of Rs.40,968/- against claim of Rs.1,06,368/- is valid or arbitrary in nature and whether OPs are negligent and deficient in their service.

          Practically in this case the complainant has not filed the discharge certificate but from the settlement intimation voucher it is found that as per clause 1.2 and 1.2(1) etc. hospital benefit can only be granted for major surgeries including heap knee joint replacement surgery, organ transplantation but in the present case no surgery was made for such treatment only plastering was done.

          So, fact remains no surgery was done but conservative treatment of plastering was made and fact remains the fracture was caused in the right hand little finger.  From the medical bills it is found that as per agreement when no surgery was made by the doctor or no operation was made, so it has become simple treatment by plastering the little finger and for which whatever may be the demand of the doctor about his fees, doctor is entitled to 25% of the demanded fees in the present case that was sent to the complainant along with settlement intimation voucher to the complainant on 06-03-2013.        

          In this regard, we have considered pre and post hospitalization charge and other charges during stay at the hospital for two days and considering the assessment of different fees and charges as made by the OP/Insurance Company is no doubt correct because it is generally setting of fracture bone of little finger having no surgery/operation.  But entire bill which was submitted by the Bell Vue Clinic, same are full of test and use of some external materials for plastering etc. and some medicine and as per policy condition and further OP sent the entire assessment sheet which is found very correct because charges were assessed as per terms of policy.

          Considering the facts, we are convinced to hold that practically the complainant is not entitled to get any amount further in view of the terms of medical policy when no surgery was made and further bills were of high rate but as per sum insured and as per conditions and terms of the policy, the complainant is not entitled to get any further benefit as the assessment of the bill by the OP/Insurance authority is justified and correct in terms of the policy and further in this case deficiency or negligent manner of service on the part of the OP is not at all found.

In the result, the case fails.

Hence,

Ordered

That the case be and the same is dismissed on contest without any cost against the OP/Insurance Company.

          OP Insurance Company to release the settle of sum at once if complainant submits return voucher dated 08-03-2013.