IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 29th day of November, 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M.Anto, Member
CC No.249/2022 (Filed on 21/11/2022)
Complainant : M.M. Philip S/o M.C. Mani,
Modayil House,
Muttambalam P.O,
Kanjikuzhi, Kottayam – 686 004.
(By Adv: V.R. Raveendran)
Vs.
Opposite parties : (1) The Manager,
United India Insurance Company Limited, omer Care Department,
Head Office, 19, IV Lane,
Nungambakkam High Road,
Chennai – 600 034.
(By Adv: Francis Thomas)
(2) The Manager,
M/s. Health India,
T.P.A Services Private Limited,
1st Floor, Door No.41/1840,
Beerankunju Road,
Kochi – 682 018.
(3) The Divisional Manager,
United India Insurance CompanyLtd.,
Divisional Office, Hillson Heights,
1st Floor, Pulimoodu Junction,
M.C Road, Kottayam.
(By Adv: Francis Thomas)
O R D E R
Sri.Manulal.V.S, President
The complaint is filed under Section 35 of the Consumer Protection Act 2019.
Case of the complainant is as follows :
The complainant has taken a Family Medicare policy vide number 1005052821P106212677 for a sum of Rs.5,00,000/- and another policy named Top Up policy for Rs.10,00,000/- from the third opposite party with a premium of Rs.32,521/- and Rs. 10,856/- each and the complainant was regularly paying the premium without any default. The said policy covering with the nominees of the complainant’s wife, daughter and son. In connection with the Discectomy operation complainant’s wife Dr.Anila Philip was admitted in the Christian Medical College, Vellore on 23/02/2022 and the surgery was done on 25/02/2022. She was discharged on 28/02/2022. The claim has sent to the second opposite party and at the initial stage Rs.1,50,000/- was approved. After accepting the final bill of Rs.1,74,294/- the opposite party transferred Rs.61,402/- at the time of discharge on 16/08/2022 and Rs.54,181/- also transferred to the complainant’s account whereas the complainant submitted the final bill of Rs.1,74,249/-. According to the complainant the opposite party has no right to reduce the bill amount without any reasonable excuse. The callous negligence and failure on the part of the opposite party resulted huge damage and expenses. The deficiency of service and latches from the part of the opposite parties caused much hardships, loss and damages to the complainant. Hence this complaint is filed by the complainant praying for an order to direct the opposite parties to pay Rs.58,711/- to the complainant along with interest and Rs.50,000/- as compensation for the deficiency in service along with Rs.10,000/- as cost of this litigation.
Upon notice from this Commission opposite parties 1 and 3 appeared before the Commission and filed version. Despite the Receipt of notice from this Commission on 21/12/2022 the second opposite party neither care to appear before the Commission nor to file version, hence the second opposite party was declared as ex-parte.
The version of the first and third opposite parties is as follows:
The complainant availed a Family Medicare policy for a period from 26/09/2021 to 25/09/2022. As per the policy the complainant, his wife and two children are insured for a sum of Rs.5,00,000/- on floater basis. The complainant had also availed a super Top Up policy with the number 1005052821P106212919 for the same period for a sum of Rs.10,00,000/-. The said insurance policies are issued subject to its terms and conditions.
The complainant’s wife Anila Philip was admitted in CMC, Vellore for treatment of Discectomy. The insured submitted a bill of Rs.1,74,250/- and the same was settled for a total amount of Rs.1,15,583/-. As per the policy the eligible room rent was Rs.5,000/- per day. But the insured had availed a room with rent of Rs.7,585/- per day. There will be proportionate reduction in the amount payable under the heads of anaesthesia charges, operation theatre charges, surgery charges, professional charges (consultation) and investigation/ laboratory charges. This is done as per the policy Clause 2.3 and 2.4. Further food and diet charges for Rs.1,585/-, registration charges for Rs.1,060/-, monitoring charges for Rs.400/-, infection control charges for Rs.2,200/-, non-medical items like thermometer surgeon’s gown and hand rub for Rs 2,315/- are not payable as per the policy. So out of total claim amount of Rs.1,74,249/- the amount payable as per the policy condition is Rs.1,15,583/- and it is paid. The rest of amount is not payable as per the policy conditions. There is no deficiency in service on the part of the first and third opposite parties.
Complainant filed proof affidavit in lieu of chief examination and marked Exhibits A1 to A7. Srinivas Aditya who is the Divisional Manager of the first opposite party filed proof affidavit in lieu of chief examination and marked Exhibits B1 and B2 from the side of the opposite parties.
On evaluation of complaint, version and evidence on record we would like to consider the following points :
(1) Whether the complainant had succeeded to prove any deficiency in service on the part of the opposite parties?
(2) If so, what are the reliefs and cost?
For the sake of convenience we would like to consider Point Nos.1 and 2 together.
POINTS 1 & 2 :-
There is no dispute on the fact that the complainant had availed a Family Medicare policy vide Exhibit A1 policy for the period from 26/09/2021 to 25/09/2022. It is also admitted by the opposite parties that the complainant had also availed a super Top Up policy vide Exhibit A2 policy for the same period. On Perusal of Exhibit A1 policy we can see that the complainant, his wife Anila Philip, Daughter Megha.T. Philip and son Akash M. Philip were the insured persons under the policy and the sum assured was Rs.5,00,000/-. It is proved by Exhibit A2 Policy that the sum assured was Rs.10 lakhs. There is also no dispute on the fact that the said Anila Philip was admitted in CMC, Vellore for the treatment of Discectomy and the complainant submitted a bill for Rs.1,74,250/- and an amount of Rs.1,15,583/- was paid by the first and third opposite parties.
The specific case of the complainant is that without stating any legal and valid reasons the first and third opposite parties disallowed Rs.58,711/- from the admissible amount as per the contract of insurance. The complaint was resisted by the first and third opposite parties that as per the policy the eligible room rent was Rs.5,000/- per day but the insured had availed a room with rent of Rs.7,585/- per day. According to the contesting opposite parties there will be proportionate reduction in the amount payable under various heads as per the terms and conditions of the policy.
The counsel for the complainant argued that the proportionate deduction clause applicable only in case of the sum assured is below Rs.5,00,000/-. The complainant had the insurance coverage of Rs.10 lakhs vide Exhibit A2 policy.
The coverage of the policy is stated in Clause 5 of the terms and condition of the B1 policy under the head of coverage. The same is reproduced hereunder :
COVERAGE
The coverages available under the policy are described below.
BASE COVERS
The policy provides base coverage as described below in this section provided that the expenses are incurred on the written medical advice of a Medical Practitioner and are incurred on medically necessary treatment of the insured person. The policy provides base coverage as described below in this section provided that expenses are incurred on the written medical advice of a medical practitioner and are incurred on medically necessary treatment of the insured person.
- In-patient Hospitalisation Expenses Cover :
We will pay the Reasonable and Customary Charges for the following Medical Expenses of an Insured Person in case of Medically Necessary Treatment taken during Hospitalisation provided that the admission date of the Hospitalisation due to Illness or Injury is within the Policy Year:
A. Room, Boarding and Nursing expenses (all inclusive) incurred as provided by the Hospital/Nursing Home up to the limits provided below:
Sum Insured | Limit (Rs.) per day |
| 1% of Sum Insured |
Rs. 5 Lacs and Above | 1% of Sum Insured or Single Occupancy Standard Air- Conditioned Room Charges whichever is higher |
These expenses will include nursing care, RMO charges,
IV Fluids/Blood transfusion/injection administration charges and similar expenses.
B. Charges for accommodation in Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (ICCU) up to the limits provided below:
Sum Insured | Limit (Rs.) per day |
| 2% of Sum Insured |
Rs. 5 Lacs and Above | Actuals |
C. The fees charged by the Medical Practitioner, Surgeon, Specialists and anaesthetists treating the Insured Person
D. Operation theatre charges,
E. Anaesthesia, Blood, Oxygen, Surgical Appliances and/ or Medical Appliances, medicines and drugs, Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/ diagnostic tests, X-Ray, dialysis, chemotherapy, radiotherapy and such other similar medical expenses related to the treatment.
1.1 Note:
a. PROPORTIONATE PAYMENT CLAUSE:
In case of admission to a room at rates exceeding the aforesaid limits in Clause V.1.A, the reimbursement/payment of all associated medical expenses incurred at the Hospital shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent.
Proportionate Deductions shall not be applied in respect of those hospitals where differential billing is not followed or for those expenses where differential billing is not adopted based on the room category.
b. No payment shall be made under 1.C other than as part of the hospitalisation bill. However, the bills raised by Surgeon, Anaesthetist directly and not forming part of the hospital bill shall be paid provided a pre-numbered bill/receipt is produced in support thereof, when such payment is made ONLY by cheque/credit card/debit card or digital/online transfer.
Therefore the opposite parties have rightly deducted the proportionate amount from the hospital bill.
On going through the operative clause of the Exhibit B2 policy we can see that any claim under the policy shall be payable by the company only if the aggregate of covered medical expenses in policy year in respect of hospitalization of the insured person (on individual basis in case of individual policy and on family floater basis in case of family floater policy exceeds the threshold stated in the schedule subject to basis payment Clause No, 7.6. Section 7.6 F Basis of Payment :
- Any claim under this policy shall be payable by the Company only if
- It is in respect of Covered Expenses specified in this policy and
- The aggregate of Covered Expenses in respect of hospitalization/s of Insured Person in case of Individual Policy or all Insured Persons in case of Family Floater Policy exceeds the Threshold Level
ii. The claim payable under this policy will be the amount by which the aggregate of such Covered Expenses in respect of hospitalizations with dates of admission falling within the policy period exceeds the higher of the following
- The Threshold Level opted for the Insured Person /family as applicable and stated in the schedule or
- The amount received/receivable under any/all Health Insurance Policies(whether or not issued by the Company)/Reimbursement Scheme and including any amount paid earlier under this policy covering the Insured person/family as applicable for such Covered Expenses, subject to multiple policy clause.
- Each claim, if more than one, during the period of this policy shall be separately subject to the above Basis of Payment.
- In no case shall the Company be liable to pay any sum in excess of the Sum Insured in aggregate of all claims during the period of this Policy.
On going through the Exhibit B2 super top up Medicare policy we can see that there is threshold limit of Rs.5 lakhs. On reading of the above, we find that under the Top-Up Medicare Policy, the insurance company has reserved its right to pay the insurance claim for medical services during hospitalization, which is over and above the sum of Rs.5 Lakhs.
As discussed earlier the insured sum under Exhibit A1 was Rs.5 lakhs whereas the expenses for the treatment of insured Anila Philip was Rs.1,74,250/-. So the argument of the complainant that the proportionate deduction is made by the first and third opposite parties is illegal will not sustain.
On the evaluation of the above discussion we are of the opinion that the complainant failed to prove his case with cogent evidence and the complaint is liable to be dismissed.
Hence the complaint is dismissed.
Pronounced in the Open Commission on this the 29th day of November, 2023
Sri.Manulal.V.S, President Sd/-
Smt.Bindhu.R, Member Sd/-
Sri.K.M.Anto, Member Sd/-
APPENDIX :
Exhibits from the side of the Complainant :
A1 - Copy of Family Medicare Policy Certificate
A2 - Copy of Super Top Up Medicare Policy
A3 - Copy of complainant’s letter dated 21/07/2022
addressed to the Customer Care Department of the
opposite party
A4 - Copy of complainant’s letter dated 05/08/2022
addressed to the Customer Care Department of the
opposite party
A5 - Copy of Lawyer Notice dated 11/10/2022 issued by
the advocate of the complainant to the opposite parties
A6(series) - Postal Receipts(3 Nos)
A7(series) - Acknowledgement Cards(3 Nos)
Exhibits from the /side of Opposite parties :
B1 - Copy of Family Medicare Policy No.1005052821P106212677
issued by the opposite parties
B2 - Copy of Super Top Up Medicare Policy No. 1005052821P106212919
issued by the opposite parties
By Order,
Sd/-
Assistant Registrar
