PER HON’BLE MEMBER SHRI. YOGESH D. KAPSE

1)  The Complainant Mr Dominic D'Souza file complaint as per section 35 of consumer protection act 2019 as on 27/02/2024.

2) The complainant file complaint against opponent no. 1 Star Health and allied insurance Co. Limited and opponent No. 2 Mr Anand Roy (M. D. and CEO).

3) The Complaint in short is as. The complainant had purchased health insurance Policy (senior citizen policy) from opponent no. 1 on 04/01/2019 by paying Rs. 15,222/- premium. Then complainant renewed the said policy each time till date by paying Rs. 91,322/- amount of premium upto the year 2024.On 07/04/2023 complainant approached the doctor because of health issue. And as per advice of doctor complainant undergo Varicose Vein Surgery. The Complainant incurred pre hospitalisation expenses of Rs. 10,830/-. There after complainant was hospitalised for surgery on 20/04/2023 and discharged on 21/04/2023. The Complainant incurred total hospitalisation expenses of Rs. 1,15,000/- of which opponent no. 1 approved  Rs. 80,500/- and rest of  Rs. 34,500/- was borne by the Complainant.

4) The Complainant also submitted complaint against opponent in the Ombudsmen at Santa Cruz in Mumbai jurisdiction. And also registered online complaint in Pune jurisdiction.

5) The Complainant’s prayer for refund amount of Rs. 48919/- from opponent and cost of Rs. 29,00,000/- for mental agony from opponent. The Complainant also prayed for litigation charges of Rs. 50,000/- from the opponent.

6) This Commission issued notice before admission to opponent. Then opponent no. 1 appeared and filed their written reply on 26/06/2024.

7) The Opponent no. 1 denied the complaint in the written version. The Opponent submitted that there is no deficiency in service on their part. The terms and condition of the policy were explained to the complainant at the time of proposing policy and also serve on the complainant along with policy schedule. The policy is subject to co- payment for some insured of Rs. 3,00,000/-, 30% each and every admissible claim. The patient was diagnosis with Varricore Vein Surgery and insured submitted a claim for authorisation for cashless. Same was approved on 18/04/2023. Then complainant filed claim on 15/05/2023. And after scrutiny claim was admitted an allowed for Rs. 80,500/-. Initially complainant submitted claim of Rs.1,15,000/- and as per the terms and condition of policy the complainant to co-pay 30% of the claim. Therefore deduction of the same Rs. 1,15,000/- - 34,500/-(30%)=80,500/-. Amount Rs. 80,500/- paid to the complainant.

8) The Complainant submitted that, the Complainant had to negotiate with opponent. Not get the total Insurance claim which was less than the total some insured amount of Rs. 3,00,000/-. And hospitalization expenses are less than sum Insured. The Opponent not abiding the IRDA Act. The Opponent providing deficiency of services by not providing critical services and also adopting unfair trade practises. In view of their acts and omission on the part of opponent no. 1 & 2 complainants filed this complaint. The Complainant also stated that he borne hospitalisation expenses of Rs. 34,500/- and also pre and post hospitalisation expenses of Rs. 14,419/- means total amount of Rs. 48,919/-. The complainant incurred Rs. 9,511/- for post hospitalisation expenses from which opponent no. 1 paid Rs. 5,922/-. The Complainant aggrieved by the act of opponent under the category of deficiency in service and unfair trade practices. The Opponent has not provided critical services to the Complainant.

9)  The Complainant approached two forum at a time, for the same cause of action. Said fact admitted by the complainant in para 12 of complaint.

10) Heard both the parties on the point of admission at length. The policy was co-payment policy and as per policy terms and condition, the insurer will pay 30% of the claim. Hence there is no deficiency in services on the part of opponent.  The Opponent no. 1 already paid the claim amount to the complainant; hence there is no deficiency in service and also nor unfair trade practices on the part of opponent. Therefore the Complaint is hereby rejected the complaint at the stage of admission with no order as to cost.