D.O.F:02/05/2023
D.O.O:11/11/2024
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KASARAGOD
CC.122/2023
Dated this, the 11th day of November 2024
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SMT.BEENA.K.G : MEMBER
M C Ashokan, aged 35 years
S/o M C Govindan (L)
Mottammal House
Beembumgal, Bedadka post,
Chengala via, Kasaragod – 671541.
(Adv: T C Narayanan) : Complainants
And
- Chief Manager
Regd. and Corporate Office,
Star Health and Allied Insurance
Insurance Company Ltd
1, New Tank Street, Nungampakkam,
Chennai – 600034.
- The Branch Manager,
Star Health and Allied Insurance
Insurance Company Ltd
2nd Floor, Arjun Towers
Bank Street, National Highway,
Taliparamba, Kannur – 670141.
(Adv: K Vinod Kumar): Opposite Parties
ORDER
SRI.KRISHNAN.K : PRESIDENT
The facts of the case in brief is that the complainant joined a Health Insurance policy, by name Family Health Optima Insurance Policy by paying Rs. 14,680/- on 21/05/2022 for the period of 21/05/2022 to 20/05/2023. The policy No. is P/181322/01/2023/001258.
The complainant was admitted in KIMS Sunrise Hospital, Kasaragod on 06/03/2023 for treatment of DENGUE FEVER and DM and applied for cashless treatment, but his request was declined by the opposite parties vide letter dated 07/03/2023 stating further evaluation is needed and he was discharged on 12/03/2023. The total treatment bill was Rs. 39,169.16/-. The complainant claimed reimbursement, but not accepted by the opposite party. The act of the opposite parties is unfair trade practice and deficiency in service. The complainant claiming re-imbursement of medical bill and compensation and cost of litigation.
The opposite party filed written version. The opposite party denies the claim of the complainant. The opposite party admitted the issue of the policy commencing from 21/05/2022 to 20/05/2023 for Rs. 3,00,000/- (Rupees Three lakhs only).
The opposite party admits having received the claim for cashless treatment. The opposite party sent a letter dated 07/03/2023 for additional documents. Hospital forwarded treatment records. He was discharged on 12/03/2023 with a discharge summary letter dated 11/04/2023 issued. As per records, sleep study report is also sent. It is only a case of Diabetes Mellitus. Claim is not repudiated. Hence not entitled to any cause of action, and claim for insurance benefit to be rejected.
The complainant filed chief affidavit and was cross examined as PW1. Ext. A1 to A3 marked. Ext. A1 is the series of Insurance policy details, Ext. A2 is the series of letter from opposite party, Ext. A3 is the series of hospital bills. The opposite party filed Ext. B1 to B2 marked. Ext. B1 is the letter dated 28/04/2023, Ext. B2 is the 1st reminder dated 13/05/2023.
In view of rival contentions, following points arise for consideration in the case;
- Whether there is any deficiency in service of opposite party in not entertaining/allowing the claim for re-imbursement of treatment charges?
- Whether the complainant is entitled for any compensation in not taking any possible action in the mediclaim? If so, for what reliefs?
The definite case of the complainant is that his claim for reimbursement is rejected without any valid reason. The opposite party admits that they received the claim. Accordingly opposite party sought production of additional documents, but additional documents are not produced. Hence claim not rejected.
The insurance company admits the issuance of the Health Insurance Policy. As per PW1, required documents were sent in e-mail by Hospital authorities, one copy directly filed by the complainant as a document in the case with intimation to opposite party.
First letter by opposite party is dated 28/04/2023 reminder is dated 13/05/2023, whereas complaint is filed on 02/05/2023 and even after reminder is sent to produce a document. According to the complainant, the copy of the documents sought for is already with opposite party supplied by Hospital via email, further copy is produced before the commission by the complainant as documents, can be verified by the opposite party.
Even during complaint, the opposite party did not take a definite stand whether they are agreeable to honour the commitment as per policy terms or not.
The opposite party has no case that it is a case whether hospitalisation is not required or complainant did not incur the expenses or not entitled to re-imbursement of medical treatment charges.
Since opposite party till date not repudiate the claim nor accepted the claim , decision is put on hold for months together amounts to deficiency in service and unfair trade practice.
The opposite party has no case that the complainant is not entitled to the hospital bill or they are not in original, or not really hospitalized or treatment records are not correct or not advised to treatment as impatient.
This commission is of the opinion that the complainant is entitled to the claim of re-imbursement of medical treatment bill of Rs. 39,169.16/- claimed in the complaint. Keeping the request to mediclaim benefits pending for a long period without valued reason, not even accepting or rejecting the request. Keeping it in hanging in balance for a long period amounts to unfair trade practice for which complainant is entitled for compensation.
In the result, complaint is allowed in part, directing opposite party to pay Rs. 39,169.16/- (Rupees Thirty Nine thousand One hundred and Sixty Nine and One Six paise only) to the complainant as treatment expenses with interest 8% per annum from the date of the complaint till payment and also directed to pay Rs. 10,000- (Rupees Ten thousand only) as compensation for deficiency in service and unfair trade practice and Rs. 5,000/- (Rupees Five thousand only) as cost of litigation to the complainant within 30 days of the receipt of the order.
Sd/- Sd/-
MEMBER PRESIDENT
Exhibits
A1 – Series of insurance policy details
A2 – Series of letter from opposite party
A3 – Series of hospital bills
B1 – letter dated 28/04/2023
B2 – First reminder dated 13/05/2023
Cross examination
PW1 – Asokan M C
Sd/- Sd/-
MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
JJ/
