Jharkhand

Bokaro

CC/28/2019

Ajay Prasad - Complainant(s)

Versus

. Star Health and Alied Insurance Co. Limited - Opp.Party(s)

Sanjay Kapoor

16 Aug 2022

ORDER

District Consumer Commission, Bokaro.

Case No. 28/2019

 Date of Filing-30-01-2019

 Date of Order-16-08-2022

Ajay Prasad S/o late Binda Prasad

 R/o Qr.No. G/C-15, DVC, CTPS Colony,

 P.O. Chandrapura, District- Bokaro, Jharkhand.

                                      Vr.

1. Star Health and Allied Insurance Co. Limited 211 & 212 2^nd Floor, Shanti Bhawan Bank more, Dhanbad 826001

2. Regional Manager, Star Health & Allied Insurance Co. Ltd. 3^rd Floor, Shop No.-304, Modi Heights Opp. AIR Station, Ratu Road, Ranchi-834004

Present:-

          Shri Jai Prakash Narayan Pandey, President

          Shri Bhawani Prasad Lal Das, Member

                                                -Order-

1. Complainant has filed this case with prayer for direction to O.Ps. for payment of Rs. 1,00,000/- with 12% per annum interest on account of medical expense incurred during his treatment and to pay Rs. 1,00,000/-  as compensation and Rs. 20,000/- as litigation cost respectively.
2. Complainant’s case in brief is that he has obtained Family Health Optima Insurance Plan of Star Health and Allied Insurance Co. Ltd. vide policy No. P/231212/01/2016/000060 valid from 11/04/2015 to 10/04/2016 and was renewed time to time for the period from 11/04/2018 to 10/04/2019 having coverage of Rs. 3,00,000/-. Further case is that due to ailment complainant was admitted in CMC Vellore on 16.05.2018 for operation of prostate etc. and discharged on 18.05.2018 during which he paid Rs. 49,079.60/- etc. to the hospital. Further case is that on request of the complainant cashless treatment was approved by the O.Ps. but under pressure of the hospital complainant was compelled to leave the hospital on 18.05.2018 by making payment etc.,  meanwhile Rs. 50,000/- was allowed by the O.Ps. in favour of the hospital but since it was already paid by the complainant hence that was not utilized by the hospital. Since complainant remained at Vellore for consultation hence he paid to the hotel for which O.P. is liable to pay it which was not paid hence legal notice was served having no impact, thereafter this case has been filed.
3. O.Ps. have filed W.S. in which facts related to purchase of insurance policy, its validity date and approval of cashless facility have been admitted.  Further reply is that on 19.05.2018 cashless approval was rejected and withdrawn hence it is prayed to dismiss the case.

 

4. Only point for consideration is that, Whether ground for denial of the claim by O.Ps. is lawful ground based on facts of the case or not? Whether Complainant is entitled to get any relief as prayed?

 

5. On perusal of the papers submitted by the parties it is apparent that Annexure-10 is the photo copy of reply dt. 21.09.2018 of legal notice served to the the O.Ps. and it has been written to the learned counsel of the complainant with copy to the  complainant. It is mentioned in that very reply that “It is also admitted that the insured patient got hospitalized on 15.05.2018 in CMC and the hospital has raised a pre-authorization request for availing cashless facility for the treatment of Benign Prostatic Enlargement. Based on the submitted documents, the cashless authorization was  processed and the approved for an amount of Rs. 50,000/- vide letter dt. 18.05.2018”. This statement itself sufficient to prove that Rs. 50,000/- was already sanctioned for the hospital expense of the complainant. Since payment was already made by the complainant to the hospital hence hospital has not accepted said amount. Therefore, we are of the view that on full satisfaction by the O.Ps. they would have allowed and processed the payment of Rs. 50,000/- but it has been refused for payment to the complainant. Complainant is being compelled to re-/observe same formalities to which hospital has already complied prior to processing of the sanction of payment. In such situation O.Ps. cannot be permitted to say something else then the act already done by them. Therefore, we are of the view that there is deficiency in service by the O.Ps. in making payment of the treatment as alleged and both the points are being decided accordingly in favour of the complainant. However, beyond the Rs. 50,000/- (the expense of treatment) other claim is not acceptable.

5   Accordingly the prayer of the complainant is being allowed in the manner indicated here in below:-

O.Ps. (Star Health and Allied Insurance Co. Ltd.)  are directed to pay Rs. 50,000/- to the complainant within 60 days from today and also to pay Rs. 10,000/- as compensation and Rs. 5,000/- as litigation cost within 60 days from today, failing which these O.Ps. shall pay interest @ 10% P.A. from 30-01-2019 ( i.e. the date on which complaint was filed) till the date of  final payment.