Kerala

Idukki

CC/60/2022

Augustin Thomas - Complainant(s)

Versus

Care Heath Insurance Ltd - Opp.Party(s)

24 Aug 2023

ORDER

 

DATE OF FILING : 6.4.2022

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the  24^th  day of  August,  2023

Present :

SRI. C. SURESHKUMAR                  PRESIDENT

SMT. ASAMOL P.                             MEMBER

SRI. AMPADY K.S.                           MEMBER

CC NO.60/2022

Between

Complainants                                          : 1.  Augustine, S/o. Thomas,

                                                                   Kalappurackal House,

                                                                   Vallayamkudy P.O.,

                                                                   Kattappana, Idukki.         

       2. Shanti Augustine, W/o. Augustine,

                                                                   Kalappurackal House,

                                                                   Vallayamkudy P.O.,

                                                                   Kattappana, Idukki.           

And

Opposite Parties                                       : 1. Care Health Insurance Ltd.,

                                                                   Regd. Office, 5^th Floor,

                                                                   19 Chowls House, Nehru Place,

           New Delhi – 110 019. 

       2. Care Health Insurance Ltd.,

                                                                   3^rd Floor, Door No.55/686,

                                                                   Vellathottam White Tower,

                                                                   Sa Road Panampally Road,

                                                                   Kochi – 682036.

(Both by Adv: Thomas Sebastian)

 

O R D E R

SMT. ASAMOL P., MEMBER

 

1.  This complaint is filed under Section 35 of the Consumer Protection Act, 2019.

 

Facts of the case are briefly discussed hereunder :

 

Complainants are husband and wife and opposite parties are functioning as Health Insurance Company.  Complainants availed a health insurance policy in the name of 2^nd complainant through M/s. Shriram City Union Finance Ltd., Kattappana and remitted premium of Rs.1008/- to the respondents.  The premium was remitted by 1^st complainant on behalf of 2^nd complainant.  At the time of joining in the said insurance, the men of opposite parties assured the complainants that all types of medical treatment needed by complainants during the validity of the policy up to five lakhs rupees will be paid by opposite parties.  The said policy was valid from 28.6.2021 to 27.6.2022.  During the validity of the said insurance policy, 2^nd complainant happened to have a slippery fall in her kitchen thereby she happened to sustain injury to the ligaments on her right hand shoulder whereby the mishap occurred on 12.11.2021.  There upon 2^nd complainant had undergone treatment at the Co-operative hospital, Kattappana and then she was shifted to the St. Mary’s hospital, Thodupuzha because there was no progress by the one month treatment she had undergone at Co-operative hospital, Kattappana.  For her treatment at Co-operative hospital, Kattappana, the bill was for Rs.2069/- and her treatment bill in total at St. Mary’s hospital, Thodupuzha was Rs.1,74,048/-, vide bills on different dates.  At St. Mary’s hospital, Thodupuzha, 2^nd complainant had undergone keyhole surgery also.  Complainants were under the impression that they will get the treatment bill and other allied expenses incurred for the treatment of 2^nd complainant will be mitigated by the policy of insurance availed from opposite parties.  After the treatment, complainants forwarded a claim of insurance before opposite parties claiming the payment of amounts expended by complainants for the treatment of 2^nd complainant during the validity of policy of insurance.  Unfortunately, opposite parties denied to grant any amount to complainants claiming that payment made by them for medical treatment is not covered by the insurance.  Also complainant contacted opposite parties in the telephone number cited in the certificate of insurance for redressal of complaints.  But no response was received by petitioner and hence this petition.  Opposite parties have no right to deny the claim of complainant on any count.  Complainants are entitled to get back the medical bill paid for treatment of 2^nd complainant and allied expenses together with compensation for delay and mental agony and pain suffered by complainants because of the denial of claim by opposite parties together with cost of this complaint.  The following releifs are prayed :

(a)  Complainants may be allowed to realise Rs.1,76,117/-, the amount of hospital bill paid by complainants together with interest @ 15% per annum from date of complaint till date of realization of the amount from opposite parties. 

(b)  Complainant may be allowed to realise Rs.1 lakh from opposite parties towards compensation for delay committed by opposite parties in allowing the claim of petitioners together with compensation for mental agony and pain suffered by complainants due to the denial of claim by opposite parties.

(c) Complainants may be allowed to realise Rs.25,000/- from opposite parties towards expenses of this litigation.

 

          2.  Upon notice from this Commission, opposite parties have appeared and filed joint  written version.  Their contentions are discussed hereunder :

 

All averments in the complaint except those that are specifically admitted hereunder are false and hence denied by this opposite party.  The complaint is not maintainable either in law or on facts of the case.  Complaint is not maintainable for want of cause of action and being pre-mature.  Complainant has only filed for cashless facility request and has not filed for any reimbursement claim.  Therefore, complaint is pre-mature and so it is not maintainable.  Cashless facility request is merely a facility being provided by the company for the benefit of its customer.  The said facility cannot be claimed as a matter of right by the customer and the company shall approve the same only when the company is sure that the claim of the claimant is payable as per the policy terms and conditions.  It is true that the 1^st opposite party issued a group health insurance policy to the group policyholder, i.e., “Shriram City Union Finance Ltd.” vide group policy No.31131155 namely “Shriram City Union Finance Ltd. – Group Care 360(SCUF-Loan-1) thereby covering its customer Mrs. Shanty Augustine vide Certificate of Insurance No.31860455 with effect from 28.6.2021 to 27.6.2022 for a sum insured upto Rs.5 lakhs subject to terms and condition in the policy.  As per condition of policy, the hospital expenses for the treatment taken in respect of critical illness mentioned in the condition of the policy alone is covered by policy.  It is true that a cashless request was received from St.Mary’s hospital on behalf of the first complainant on 11.1.2022.  As per the pre-authorisation form, the 2^nd complainant on 12.11.2021 got her right shoulder injured due to impact on fall in her house and was provisionally diagnosed with rotator cuff tear right shoulder.  The first opposite party upon perusal of the documents, observed that injury or illness suffered by the 2^nd complainant is not covered in her health insurance policy.  As per the schedule of benefit mentioned in the policy certificate, the 1^st opposite party is only liable to pay the hospital expenses for the treatment taken in respect of 4 critical illnesses mentioned in the policy. 

 

The treatment taken for the injury or illness suffered by 2^nd complainant does not fall under the category of 4 critical illnesses.  1^st opposite party is only liable to pay the hospitalization expenses of the complainant if she had taken the treatment in respect of 4 critical illness mentioned in policy.  The four critical illness are cancer of specified severity, Myocardial Infraction, 3 open chest CABG and stroke resulting in permanent symptoms.  Since the treatment to be taken for the injury suffered by the 2^nd complainant not falls under the category of 4 critical illness, 1^st opposite party rejected the cashless request and same was communicated via email to St. Mary’s hospital on 12.1.2022.  As per the schedule of benefit mentioned in the policy certificate, 1^st opposite party is only liable to pay the hospital expenses for the treatment taken in respect of 4 critical illness.  Coverage for critical illness is limited to the definitions and extent of coverage stated in clause 1.2.20 of the conditions of the policy.  As per conditions of the policy the coverage is only for critical illness opted.  Hence opposite parties are not liable to pay any amount against the claim of complainant.  Complainants have not submitted reimbursement claim, medical records and treatment bills to opposite parties.  2^nd complainant has submitted only cashless facility request.  Further, as per the medical certificate issued by the Co-operative hospital dated 8.1.2022, it is mentioned that 2^nd complainant sustained the injury to her right shoulder on 12.11.2021 and was radiologically diagnosed as rotator cuff teat right shoulder.  Since the treatment required for injury suffered by the 2^nd complainant not falls under the category of 4 critical illness, 1^st opposite party rejected the cashless request.  As the injury suffered by the 2^nd complainant does not fall under the category of 4 critical illness, complainants are not entitled to get reimbursement of treatment expense from these opposite parties.  Complaint is filed only as an experimental one without any cause with malafide intention to bargain with the opposite parties for illegal gain.  The reliefs prayed for are not allowable.  The insurance claim of Rs.1,76,117/-  with interest @ 12% per annum, Rs.25,000/- towards cost of the proceedings and compensation of Rs.1 lakh for delay in allowing the claim, mental agony and pain suffered by the complainants due to denial of the claim are not allowable and opposite parties are not bound or under any liability to pay insurance claim, cost and compensation to complainants.  Hence it is humbly prayed that this Forum may be dismissed the petition against the opposite party with costs of the opposite party. 

 

          3.  Thereafter, this case was posted for evidence.  Counsel for complainants have submitted that they have no oral evidence.  Exts.P1 series 6 in numbers, to Ext.P4 were marked.  No oral evidence was adduced by opposite parties also.  Exts.R1 to R4 were marked.  Both parties have not filed argument notes. There was no representation for both on 4.7.2023 even case was posted for hearing. Hence, it was taken for orders.  Now the points which arise for consideration are :

1)  Whether there is any deficiency in service on the part of opposite parties ?

2)  If so, what reliefs the complainants are entitled for ?

 

4.  Points 1 & 2 are considered together :

 

          Complainants have not filed proof affidavit.  Documentary evidence was only adduced by complainant.  We have perused complaint and marked documents.  Complainants allege that they have availed a health insurance policy during the period from 28.6.2021 to 27.6.2022 from opposite party.  Ext.P3 is copy of certificate of insurance.  As per Ext.P3, it is proved that complainants have taken insurance from opposite party through Sriram City Union Finance Ltd., during the alleged period.  Complainants state that as per this policy, all types of medical treatments were assured by opposite party.  But, opposite party contended that the hospital expenses for the treatment taken in respect of critical illness mentioned in the condition of the policy alone is covered and the treatment taken for the injury or illness suffered by 2^nd complainant does not fall under the category of 4 critical illness, hence 1^st opposite party is only liable to pay the hospitalization expenses of complainant, if she had taken the treatment in respect of 4 critical illness mentioned in the policy.  On perusal of Ext.P4, i.e., copy of medical certificate issued from co-operative hospital, Kattappana, we find that 2^nd complainant was clinically and radiologically diagnosed as rotator cuff tear right shoulder and she was treated with analgesics from 13.11.2021 to 25.11.2021.  Moreover, complainants stated in complaint that 2^nd complainant was under the treatment of ligaments on her right hand shoulder during the validity period of the insurance policy and after the treatment, they have applied claim of insurance amount.  As per Ext.R3, i.e., repudiation letter from opposite party, it is seen that opposite party has informed to complainants that they are unable to process cashless benefit, because it is not covered as per policy conditions.  On the perusal of Ext.P3, i.e., policy certificate, it is evident that inpatient care for 4 critical illness alone is permissible upto sum insured.  Ext.R1 is also copy of policy certificate along with policy conditions.  We have carefully perused these Ext.R1 document.  The clause 1.2.20 of the conditions of policy is specified in Ext.R1 document.  Coverage for critical illness is limited to the definitions and extent of coverage stated in such clause.  It is seen that the injury suffered by 2^nd complainant is  not covered under the categories of critical illness specified in clause 1.2.20 of policy conditions.  Complainant has not adduced evidence to prove that opposite party had assured that all types of medical treatment are covered under this policy.  As per the policy conditions, opposite parties are not liable to pay the claim amount in respect of treatment of 2^nd complainant.  Hence, we are of the considered view that there is no deficiency in service on the part of opposite parties.  As a result, complaint is dismissed without cost.  Points are answered accordingly.

 

          Pronounced by this Commission, on this the   24^th  day of August, 2023

               

                                                                                               Sd/-

SMT. ASAMOL P., MEMBER

                      Sd/-

  SRI. C. SURESHKUMAR, PRESIDENT

                             Sd/-

SRI. AMPADY K.S., MEMBER

 

 

APPENDIX

 

Depositions :

Nil.

Exhibits :

On the side of the Complainant :

Ext.P1 series  -  Copy of hospital bills – 6 Nos.

Ext.P2 series  -  Copy of hospital bills – 14 Nos.

Ext.P3            -  Copy of certificate of insurance.

Ext.P4            -  Copy of medical certificate dated 8.1.2022.

On the side of the Opposite Party :

Ext.R1            -  Copy of policy certificate along with policy conditions.

Ext.R2            -  Copy of request for cashless hospitalisation for Medical Insurance Policy.

Ext.R3            -  Copy of repudiation letter from opposite party.

Ext.R4            -  Copy of medical certificate dated 8.1.2022.

 

                                                                                                          Forwarded by Order,

 

 

 

                                                                                 ASSISTANT REGISTRAR