By. Sri. Ananthakrishnan. P. S, President:
This is a complaint filed under section 12 of the Consumer Protection Act 1986.
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2. The complainant’s case in brief is as follows:- The Complainant had taken a medical insurance policy from second and third Opposite Parties through their agent, first Opposite Party under the name and style “Senior Citizens Red Carpet Health Insurance Policy” from 27.04.2011 onwards and which is being renewed. During the validity of the policy, the Complainant was admitted at Leo Metro Cardiac Centre, Kalpetta on 29.12.2017 due to chest discomfort. Then the Complainant was undergone angiogram and thereafter angioplasty and was discharged on 01.01.2018. The Complainant informed about her admission on the date of admission itself to the office of the second and third Opposite Parties through first Opposite Party and before discharge, she had tried to contact the Opposite Parties for settlement of her claim. But, they had not responded. So, she directly paid her hospital expenses of Rs.1,13,808/-. Thereafter, she sent the claim form with medical bills to second and third Opposite Parties through first Opposite Party to get the amount reimbursed. But the second and third Opposite Parties only reimbursed Rs.56,560/- through the bank account of Complainant. Even though, the Complainant requested the Opposite Parties to reimburse the balance amount, they did not respond to her request. This act of the Opposite parties amount to deficiency in their service. Thus Opposite Parties are legally
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liable to pay compensation of Rs.50,000/- towards loss, damages and mental agony caused to the Complainant. She is also entitled to get repayment of the balance amount of Rs.57,248/- and cost. Hence this complaint.
3. The first Opposite Party is ex-parte.
4. The second and third Opposite Parties filed version contenting as follows:-
They admitted that the Complainant had taken a policy from them under the name and style “Senior Citizens Red Carpet Policy” and she renewed the policy up to 26.04.2018. At the time of joining in the policy, the Complainant was supplied the terms and conditions of the policy. It is clearly stated in the policy schedule that the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. They admitted that the Complainant was admitted at Leo Metro Cardiac Centre, Kalpetta on 29.12.2017 for treatment of Coronary Artery Disease-Acute Coronary Syndrome, Rheumatoid Arthritis and underwent PTCA with stent to LAD and was discharged on 01.01.2018. They also admitted that the Complainant submitted a claim form for Rs.1,13,808/-. The Opposite Parties had made deduction from this amount as per the terms and conditions of
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the policy. Based on it, Opposite Parties allowed an amount of Rs.57,650/- to the Complainant. Thus they had paid full admissible amount to the Complainant. There has been no delay, negligence or default or latches in processing the claim of the Complainant. Hence Complainant is not entitled to get any further amount. She is also not entitled to get any compensation and cost from these Opposite Parties. The Complainant has filed this complaint only to harass the Opposite Parties for getting undeserved amount. Hence this complaint is to be dismissed with cost of these Opposite Parties.
5. On the above contentions, the points raised for consideration are:-
1. Whether there is any deficiency in service on the part of
Opposite Parties. If so, whether the Complainant is entitled to get
anything as claimed?
2. Reliefs and Cost.
6. The evidence in this case consists of oral testimony of PW1, OPW1, Ext. A1, A2 and Ext.B1. Heard both sides.
7. Point No.1:- The Complainant’s case is that even though she took a medical insurance policy under the name and style “Senior Citizens Red Carpet Health Insurance Policy” from second and third Opposite Parties and incurred an
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expenses of Rs.1,13,808/- when she was treated for heart disease at Leo Metro Cardiac Centre at kalpetta, second and third Opposite Parties have not given full claim amount to her. On the other hand, second and third Opposite Parties contented that they had given full admissible amount to the Complainant as per the policy conditions. They contended that the claim under this policy is subject to conditions, clauses, warranty, exclusions etc attached with the policy. There is no dispute that the Complainant had taken the said policy and that she was treated at Leo Metro Centre Kalpetta and that she incurred an expenses of Rs.1,13,808/- for treatment. So also, here, there is no dispute that Complainant submitted a reimbursement claim for Rs.1,13,808/- before the second and third Opposite Parties. Ext.A1 is the Policy Certificate. Ext.A2 is the bill received by the Complainant from the Leo Metro Cardiac Centre, Kalpetta for Rs.1,13,808/-. So, total amount claimed by the Complainant is Rs.1,13,808/-. But, the second and third Opposite Parties have given only Rs.56,560/- to the Complainant. According to them, it is the admissible amount as per the policy. Therefore, they contented that Complainant is not entitled to get the balance of Rs.57,248/-. So, let us consider whether the Complainant is entitle to get anything more. The dispute is with regard to room rent, service charge, medical bills, primary charge, disposable items and observation rent mentioned in Ext.A2 certificate. The Opposite Parties
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allowed some of the claims of the Complainant coming under other categories. The second and third Opposite Parties contented that they can give amount basing only upon the terms and conditions of the policy. Ext.B1 is the policy conditions. Ext. B1, contains a coverage clause and as per this clause there are some conditions to allow each claim. As per section A of the coverage clause, the room, boarding and nursing expenses can be allowed at 1% of the sum assured subject to a maximum of Rs.6,000/- per day. Here, the sum assured is Rs.1,00,000/-. It is evident that the Complainant was admitted in the hospital for three days. She stayed in a room for one day and in CCU for 2 days. The Opposite Parties allowed Rs.3,500/- as rent for 2 days admission in CCU plus nursing charges. But they allowed only Rs.1,000/- towards the room rent for one day. As per section A of coverage clause, the Complainant is entitled to get 1% of sum insured subject to a maximum of Rs.6,000/- per day towards room rent and nursing charges. She claimed Rs.2,850/- towards the room rent and Rs.350/- towards the service charge for one day. Since, she is entitled to get Rs.6,000/- per day towards these heads, no doubt, she is entitled to get Rs.2,850/- plus Rs.350/- as rent and nursing charges for one day. She was given only Rs. 1000/- towards this claim. So she is entitled to get Rs.2,200/- more. The next dispute is with regard to the medical charges. As per section D of coverage clause, the
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Complainant is entitled to get 50% of the sum assured for anaesthesia, blood, oxygen, operation theatre charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker and similar expenses per hospitalization. So, she is entitled to get Rs.50,000/- in total for anaesthesia, blood, oxygen, operation theatre charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker and similar expenses. The complainant claimed Rs.22,500/- towards medicine charges and the opposite parties allowed only Rs.5,540/-. As I already stated, the medical expenses including the medical bills are coming under section D of the coverage clause in Ext.B1. As I already stated, complainant is entitled to get Rs.50,000/- towards these expenses. Even though, the Opposite Parties mentioned about some classes specifically in the said clause in Ext. B1, the insured person is also entitled to get similar expenses as per this clause. The opposite parties have given Rs.35,600/- towards the expenses for angioplasty, Rs.920/- towards the expense in lab, Rs.400/- towards ECG expenses, Rs.1,000/- towards the expenses for Echo test, Rs.1,000/- towards the expense for cardiac monitor, Rs.540/- towards blood and Rs.5,000/- towards contrast (medicine charges). Even though, these classes are not mentioned specifically in this clause, these expenses will come under the
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head “similar expenses” mentioned in this clause. The opposite parties have given Rs.44,460/- under these heads. The complainant is not entitled to get more than Rs.50,000/- for the expenses coming under this section. So, the Complainant is entitled the balance alone towards medical charges. Therefore, the Complainant is only entitled to get Rs.5,540/- for medicines. As per section C of this clause, the complainant is entitled to get a maximum of Rs.25,000/- of the sum assured per hospitalisation for Surgeon, Anaesthetist, Medical Practioner, Consultants and specialist fees. The opposite parties allowed Rs.24,400/- towards Surgeon fees and Rs.600/- as consultation fees as claimed by the Complainant. Further, she wants to get Rs.10,000/- towards diagnostic charge, Rs. 148/- towards the expenses for disposable items and Rs.5,000/- as observation rent. There is no provision in the coverage clause to get observation rent and disposable items even if, the diagnostic charge will come under section D. Since the Opposite Parties have given Rs.50,000/- to the complainant in total for the expenses noted in section D, she is not entitled to get any further amount under the head diagnostic charge. Therefore the Complainant is only entitled to get Rs.2,200/- from the opposite parties. So it can be held that there is some deficiency in service on the opposite parties. The complainant claims Rs.50,000/- as compensation for loss, damages and mental agony. Considering the facts of the
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case, according to me, the complainant is entitled to get only Rs.1,000/- towards compensation for loss, damages and mental agony and Rs.500/- towards cost. Therefore the point is answered accordingly.
8. Point No.2:- Since we found point No.1 as discussed above, the complainant is entitled to get a partial relief.
In the result the complaint is partly allowed. The Opposite Parties are directed to give Rs.2,200/- (Rupees Two Thousand Two Hundred) towards the balance claim, Rs.1,000/- (Rupees One Thousand) as compensation and Rs.500/- (Rupees Five Hundred) as cost to Complainant within 30 days from the date of receipt of this order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 6th day of February 2020.
Date of Filing: 02.07.2018.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
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APPENDIX.
Witness for the complainant:-
PW1. Sumit Sreedhar. Teacher.
Witness for the Opposite Parties:-
OPW1. Manu Mohan. Assistant Manager, Claims,
Star Health and Allied Insurance Co Ltd.
Exhibits for the complainant:
A1. Copy of Senior Citizens Red Carpet Health Insurance Policy.
A2. Copy of Inpatient Summary. Dt:01.01.2018.
Exhibits for the opposite parties:-
B1. Customer Information Sheet- Senior Citizens Red Carpet Health
Insurance Policy.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
SENIOR SUPERINTENDENT,
CDRF, WAYANAD.
