ORDER

(13/08/2024)

Per Ms.Poonam V. Maharshi – Member:

(1) Being aggrieved with the order dated 12/10/2017 passed by the District Consumer Disputes Redressal Commission, Mumbai Suburban in Complaint No.15 of 2015 the original complainant has preferred this appeal. Parties to this appeal shall be called and referred as per their status in the original complaint.

(2) Brief facts leading to file this appeal can be summarized as under:

The Complainant has availed from opponent no.1 a Mediclaim Insurance Policy No.140400/-34/13/25/00000559 for sum assured of Rs.2,50,000/- (hereinafter referred to as ‘said policy’). The complainant has paid premium regularly. The Complainant was admitted in Lilavati Hospital and Research Centre (hereinafter referred to as ‘said hospital’) on 8th December, 2013 to 12th December, 2013 for the complaint of chronic retention of urine. The Complainant has undergone the said treatment under the care of Dr.Anup P. Ramani (hereinafter shall be referred as ‘said surgeon’). The said policy was in force at the relevant time. The opponents were informed about the same on the date of admission i.e. on 8th December, 2013 and accordingly, the complainant filed an insurance claim of Rs.2,76,281/- with the opponent no.1 including Rs.1,50,000/- paid through cheque to the said surgeon. However, out of the said amount of Rs.1,50,000/- the opponent deducted the amount of Rs.1,30,000/- while unreasonable relying only on the Note No.2 of Section 2.3 and 2.4 and it allowed only amount of Rs.20,000/- out of said entire amount of Rs.1,50,000/-. Accordingly, the complainant filed his claim of Rs.2,76,281/- with the opponent no.1 but the opponent has allowed only amount of Rs.98,134/- towards the claim. Hence, the complainant had filed the present complaint alleging deficiency in service against the opponents with the prayer to pay amount of Rs.1,51,866/- being the difference amount between the amount paid and the sum assured along with interest, compensation and costs.

(3) Notice of the complaint was issued to the opponent nos.1 and 2.

Though opponent no.2 was duly served it failed to appear before the Commission and hence, ex-parte order came to be passed against opponent no.2.

(4) The opponent no.1 appeared and filed its written statement. The opponent has admitted that the complainant is holder of policy issued by opponent no.1. It was contended that the complainant has not denied the policy document and the terms and conditions of the policy which is a part and parcel of the policy i.e.Mediclaim Policy 2012. The complainant has himself not annexed any policy document to support his contentions. The opponent has rightly settled the claim for amount of Rs.98,134/- within the parameters of the terms and conditions of the policy i.e. Mediclaim-2012 which is relevant in this case. The settled amount is accepted by the complainant without any condition or protest At the time of receiving the said amount. Therefore, the complainant is not entitled for any further claim from the opponent in any manner whatsoever. As per Clause 3.9 of Mediclaim Policy-2012 ‘no payment shall be made for any Hospitalisation expenses incurred, unless they form part of the Hospital Bill. However, the bills raised by Surgeon, Anaesthetist directly and not included in the Hospital Bill shall be paid provided a numbered Bill is produced in support thereof, for an amount not exceeding Rs. Ten thousand, where such payment is made in cash and for an amount not exceeding Rs. Twenty thousand, where such payment is made by cheque”. In this case the payment has been directly made to the surgeon by the complainant through cheque, therefore, in spite of the said bill the amount of Rs.20,000/- is settled as per said clause in the terms and conditions of the policy i.e. Mediclaim-2012. Hence, it is prayed that the complaint be dismissed.

(5) The Complainant and opponent led their evidence. On going through the evidence on record the District Commission allowed the complai