Order by:

Smt.Aparana Kundi, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant availed a health insurance policy covering himself and his family from Opposite Parties on 11.11.2014, which got renewed from time to time. Lastly the complainant purchased the policy on 11.11.2023. Unfortunately, on 10.06.2023, the complainant was admitted in CKOSMIC Health City and after treatment got discharged from the hospital on 13.06.2023. At the time of treatment and after discharge from the hospital, the complainant requested the Opposite Parties to pay the medical expenses including pre and post, to the complainant, but the Opposite Parties did not pay the expenses of treatment and thus, the complainant has to pay whole of the amount from his own pocket. After the treatment, the complainant submitted all the medical record with Opposite Parties as per their demand, but despite that the Opposite Parties has not paid any amount in lieu of medical expenses to complainant. Alleged that the complainant spent Rs.1,60,000/- for his treatment from his pocket (including all pre and post expenses). Alleged further that inspite of repeated requests, demands and representations, the Opposite Parties approved only Rs.1,08,950/- to complainant vide approval letter dated 01.08.2023 on the basis of false and baseless reason and not released the balance amount. Due to such act and conduct of the Opposite Parties, the complainant has suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to release the amount of Rs.51,582/- alongwith interest @ 24% p.a. till its realization

b)      To pay an amount of Rs.30,000/- as compensation on account of mental tension and harassment and for deficiency in service.

c)       To pay an amount of Rs.22,000/- as litigation expenses.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the intricate questions of law and facts are involved in the present complaint which required voluminous documents and evidence for determination, which is not possible in the summary procedure under C.P. Act; the complainant has concealed material facts and documents from this Commission as well as from the Opposite Parties, therefore, the complainant is not entitled to any relief. The complainant has concealed the fact that he has violated the terms and conditions of policy in question and no PED was declared and the policy was going on in the company since 2014 and the real facts are that the complainant availed the ‘Family Health Optima Insurance Plan Policy No.P/211222/01/2023/007846 renewed for the period 12.11.2022 to 11.11.2023 and in this policy Lalit Mohan Garg, complainant, Sunita Garg Spouse and Manav Garg Dependant Child were insured for an amount of Rs.5 lakh.  Averred that terms and conditions of the policy were explained to the complainant at the time of proposing the policy and same were served to the complainant alongwith policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the insured has submitted the claim documents in the present case regarding the medical reimbursement expenses towards treatment taken by him in CKOSMIC Health City at Moga from 10.06.2023 to 13.06.2023 towards the Injunial Hernia. On perusal of applying reimbursement and after seeking record, medical team of the Opposite Parties regarding this claim for the period 10.06.2023 to 13.06.2023 and amount of Rs.1,08,950/- was approved and paid through NEFT No.216232580105166 dated 04.08.2023 and the detail of deduction were also given to complainant qua claim no.CIR/2024/211222/0341595 as per the policy terms and conditions. The reason for the deductions during hospitalization period are:-

i.        As per the excluded expenses of the policy, in sub head ICU Charges; expenses are reasonable and necessarily incurred is allowed in terms of policy condition….. Monitor and Oxymeter not payable, Rs.2000/- are deducted.

ii.       As per the other excluded expenses of the policy, in sub head OT Charges: expenses are reasonable and necessarily incurred is allowed in terms of policy condition… Rs.15,000/- are not payable.

iii.      As per the other excluded expenses of the policy, in sub head Professional Fees (Surgeon, Anesthetist, Consultation Charges etc.: expenses are reasonable and necessarily incurred is allowed in terms of policy condition… Rs.15,000/- are not payable.

iv.      As per the other excluded expenses of the policy, in sub head medicines within hospital: the charges pertaining to disponge, gloves blade, fixer, 3 way, Jelly, Cover, Uro Bag, Scrub, Solution, Scrub, Veinoline, Cath, Infusion not payable, Rs.3109/- are deducted.

v.       As per the other excluded expenses of the policy, in sub  head b.i) Consumables – within Hospital: expenses are reasonable and necessarily incurred is allowed in terms of policy condition… Rs.15,941/- are not payable.

vi.      Hospital Discount Rs.532/- is not payable.

          The amount of Rs.108950/- is the maximum payable as per terms and Conditions of the policy and the same was already paid to the insured. Averred further that the complainant has no locus standi or cause of action to file the present complaint against the Opposite Parties; the complaint is not maintainable in the present form; the complainant has violated the terms and conditions of the policy. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C7.

4.       On the other hand, Opposite Parties have placed on record copies of documents Ex.OP1 to Ex.OP8 and affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP9.

5.         We have heard the ld. counsel for both the parties and also gone through the record.

6.       It is well proved on record that the complainant is the holder of Insurance policy namely “Family Health Optima Insurance Plan” having no.P/211222/01/2023/007846 for the period 12.11.2022 to 11.11.2023. It is also proved that during the policy period, the complainant got admitted in CKOSMIC Health City at Moga for the treatment of Injunial Hernia remain admitted in the hospital from 10.06.2023 to 13.06.2023 period. It is also admitted on record that the complainant lodged the claim with Opposite Parties for reimbursement of the expenses of Rs.160,000/- and out of which, the Opposite Parties allowed the amount of Rs.1,08,950/- and has not paid the remaining amount of Rs.51,050/- and the said deduction of Rs.51,050/- has been challenged by the complainant through this complaint.

7.       The Opposite Parties has taken the plea that the complainant has violated the terms and conditions of the policy and concealed the pre existing disease before taking the policy in question. Here it is pertinent to mention that the policy in question has been purchased by the complainant since 2014 and after so many years, the question of pre existing disease raised by the Opposite Parties is quite surprising. Moreover after 3-4 years of continuation of the policy, pre existing disease itself covered under the policy plan as per IRDA Guidelines issued vide letter no.IRDAI/HLT/REG/CIR/046/02/2020 dated 10.02.2020, which is reproduced as under:-

Pre-existing disease means any condition, ailment, injury or disease; that is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement.

So, if we go by the guidelines as referred above, the question of pre existing disease raised by the Opposite Parties is not maintainable as the complainant is availing the policy from the Opposite Parties since, 2014. Further the reason for paying less amount than claimed amount to the complainant, the Opposite Parties said that as per policy terms and conditions, they have made some deductions in the amount, but it is again surprising on the part the of the Opposite Parties that they have not placed on record any documentary evidence, which clearly shows that on what account the deductions have been made by the Opposite Parties. Even the Opposite Parties have not highlighted the term and condition in the terms and conditions booklet on the basis of which deductions have been made. Perusal of the record reveals that the Opposite Parties have made deductions in the amount incurred by the complainant for the hospitalization under the different heads i.e. ICU Charges; OT Charges; Professional Fees (Surgeon, Anesthetist, Consultation Charges etc; medicines within hospital; consumables within hospital and Hospital Discount Rs.532/-, but the deductions made by the Opposite Parties are not genuine as specific terms and conditions regarding deductions of these expenses has not been placed on record or not pointed out by the Opposite Parties in deductions column of the terms and conditions booklet.

8.       From the above discussion, we are of the considered view that Opposite Parties failed to justify the deductions so made by them.

9.       Sequel to the above discussion, the instant complaint is allowed in part and Opposite Parties are directed to pay remaining amount of Rs.51,050/- (Rs.1,60,000/- actual amount after discount minus Rs.1,08,950/- paid amount = Rs.51,050/- remaining amount) to the complainant. Further the Opposite Parties, jointly and severally, are directed to pay an amount of Rs.4,000/-(Rupees Four Thousand only) as compensation on account of harassment. Also the Opposite Parties are liable to pay Rs.3,000/-(Rupees Three Thousand only) for thrusting avoidable litigation, to the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, they are further burdened with additional cost of Rs.5,000/-(Rupees Five Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission