Dt. 11.01.16

JAGANNATH BAG, MEMBER

       The present appeal is directed against the Order,  dated 16.06.2014, passed by the Ld. District Consumer Disputes Redressal Forum, Kolkata, Unit-II, in CC No. 292 of 2013, whereby the complaint was allowed on contest against the OPs,  but without any cost.

       The Complainant’s case, in brief , was as follows:       

      The Complainant had taken a Mediclaim policy from the Opposite Party No.1, insuring himself and his family members consisting of his wife, son and mother. While the policy was valid between 05.3.2012 and 04.3.2013, Complainant’s mother was  admitted in Fortis Hospital Ltd. on 18.4.2012 for her respiratory problem, but unfortunately expired on 18.5.2012.The Complainant, in terms of the insurance policy cover , filed his claim for reimbursement of the medical expenses amounting to Rs. 3,47,102/- with the OP No. 2, being the TPA of the Opposite Party No. 1.  After delay of more than 4 months from the date of filing of the claim , the OP No. 2 sent a cheque of Rs. 1,77,550/- dated 22. 11. 2012 along with a claim payment statement dated 23.10.2012 , which showed an arbitrary deduction of a total sum of Rs. 1,69,523/-. The Complainant by his letter dated 14.12.2012 asserted that the deductions shown in the statement dated 23.10.2012 were incorrect,  false , vague and ambiguous as no particulars of the alleged inadmissible expenses were disclosed by the OPs and that in accordance with the calculation done by the Complainant Rs.1,29,375/- has been short paid by the OPs. An Advocate’s notice was sent on 11.02.2013 demanding the balance  admissible claim of Rs. 1,29,375/-.The Complainant waited for reply,  but having no favorable response,  lodged the consumer complaint praying for direction upon the OPs /Appellants to pay the balance admissible amount of Rs.1,29,375/- and also compensation of Rs. 10,000/- for mental agony and pain caused due to negligence in service on the part of the OPs.

    The complaint was contested by the OPs by filing written version, wherein it was contended that the complaint was barred by limitation. It was also contended that out of the total claim lodged by the Complainant Rs.1,77,550/- was sanctioned in accordance with the terms and conditions of the policy which was accepted by the Complainant /Respondent. No documents were provided showing any calculations towards demand of the balance amount. There was no deficiency in service on the part of the OPs . The Complainant was estopped from claiming any further amount in regard to reimbursement of the medical expenses. The complaint was, therefore, liable to be  dismissed.

    Ld. Forum below  after having considered the materials on record and the arguments as advanced by the Ld. Lawyer of the OP observed that the OP granted Rs. 88,400/- against the claim of Rs. 1,19,000/- as room charges and ICU charges. Again Ld. Forum  observed that the OP wrongly deducted Rs. 99,302/- for room and ICU and other nursing charges.  Ld. Forum below concluded that  as per policy condition deduction would be Rs. 49,000/- and hence, balance Rs. 51,00