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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
V.K. Jain, Presiding Member
New India Assurance Co. Ltd. —Petitioner
versus
A.K. Kariappa —Respondent
Revision Petition No.766 of 2011
(Against the Order dated 29/11/2010 in Appeal No. 3925/2009 of the State Commission Karnataka)
Decided on 2.6.2015
Counsel for the Parties:
For the Petitioner:Mr. Navdeep Singh, Advocate
For the Respondent:Mr. B.E. Soma Lokanatha, Advocate
IMPORTANT POINT
Insurance Company cannot resort to undue deductions without any basis.
Headnote:Consumer Protection Act, 1986—Sections 15, 17, 19 and 21—Insurance—Mediclaim Policy—Part settlement of Mediclaim—District Forum directed petitioner company to pay sum of Rs.33,075/- to complainant being balance amount of claim alongwith compensation quantified at Rs.5,000/- and cost—Policy amount being Rs.1 Lakh, room boarding and nursing expenses were required to be restricted to Rs.1,000/- per day—Considering that actual amount paid by complainant was much higher, cannot be disputed that complainant was entitled to room rent only at Rs.1,000/- per day—Procedure adopted by insurance company was faulty—Instead of making proportionate deduction from charges paid by complainant to hospital it ought to have inquired from concerned hospital as to what exactly would be charges payable in case room rent was Rs.1,000/- per day—It would be necessary for Insurance Company to make inquiry in this regard from Hospital and find out what would be applicable charges for room to which insured is entitled under terms of policy—However, since no such exercise was undertaken by Insurance Company, deduction made by it except in respect of room rent was not justified—Petitions disposed of with directions. (Paras 7 to 9)
Result : Revision Petition disposed of.
V.K. Jain, Presiding Member—The respondent/complainant obtained a group medi-claim policy from the petitioner company for the period from 16.09.2007 to 15.09.2008 for a sum of Rs.1 lakh. The complainant/respondent had to undergo surgery and medical treatment at Sita Bhateja Speciality Hospital incurring expenditure to the extent of Rs.76,309.84 on the said treatment. The claim lodged by him, however, was restricted by the Insurance Company to Rs.34,389/-. Being aggrieved, the complainant approached the concerned District Forum seeking payment of the balance amount alongwith damages and cost of proceedings.
2. The complaint was resisted by the Insurance Company primarily relying upon the note below clause 2 of the Insurance Policy whereby insurance company was under obligation to pay the Surgeon, Anaesthetist, Medical Practitioner, Consultants’ Specialist fees, anaesthesia, blood, oxygen, OT charges, surgical appliances, medicines and drugs, dialyses etc. was restricted to the charges applicable to the category of the room to which the insured was entitled under the said policy. The entitlement for room was restricted to a maximum of 1% of the sum insured per day or actual amount whichever was less.
3. Vide its order dated 14.10.2009, the concerned District Forum directed the petitioner company to pay a sum of Rs.33,075/- to the complainant being the balance amount of the claim alongwith compensation quantified at Rs.5,000/- and cost of litigation quantified at Rs.1,000/-.
4. Being aggrieved by the order passed by the District Forum, the Insurance Company approached the concerned State Commission by way of an appeal. The said appeal having been dismissed vide impugned order dated 29.11.2010, the Insurance Company is before this Commission by way of this revision petition.
5. The learned counsel for the petitioner submits at the very outset that though they have already paid the entire amount which was payable to the complainant in terms of the order of the District Forum and the amount involved is rather small, they have approached this Commission with a view to have an authoritative pronouncement on the obligation of the Insurance Company in the light of the terms and conditions of the medi-claim policy issued by it.
6. Clause 2 of the Medi-claim policy taken by the complainant reads as under:-
“2.0 Following reasonable, customary & necessary expenses are reimbursable under the policy:
2.1 Room, boarding and nursing expenses as provided by the Hospital/Nursing Home not exceeding 1.0% of the sum insured (excluding Cumulative Bonus) per day or actual amount, whichever is less.
2.2 Intensive Care Unit (ICU)/Intensive Cardiac Care Unit (ICCU) expenses not exceeding 2.0% of the sum insured (excluding Cumulative Bonus) per day, or actual amount, whichever is less
2.3 Surgeon, Anaesthetist, Medical Practitioner, Consultants’ Specialist fees.
2.4 Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like pacemaker, Relevant Laboratory/Diagnostic test, X-Ray and other medical expenses related to the treatment.
2.5 Pre-hospitalisation medical charges upto 30 days period immediately before the insured’s admission to hospital for that illness or injury.
2.6 Post hospitalisation medical charges upto 60 days period immediately after the insured’s discharge from the hospital for that illness or injury.
Note:
1. The amounts payable under 2.3 and 2.4 shall be at the rate applicable to the entitled room category. In case insured opts for a room with rent higher than the entitled category as under 2.1, the charges payable under 2.3 and 2.4 shall be limited to the charges applicable to the entitled category.”
7. It would thus be seen that as far as room, boarding and nursing expenses are concerned, the liability of the insurance company cannot exceed 1% of the sum insured or the actual amou
