Complaints filed on: 16-12-2023
Disposed on:20-07-2024
BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, TUMAKURU
+
DATED THIS THE 20th DAY OF July, 2024
::P R E S E N T::
SMT.G.T.VIJAYALAKSHMI, B.Com, L.L.M, ….....PRESIDENT
SRI.KUMARA.N, B.Sc.,(Agri) L.L.B., M.B.A.,……….. MEMBER
SMT.NIVEDITA RAVISH, B.A., L.L.B. (Spl)., .LADY MEMBER
CONSUMER COMPLAINT No. 179/2023
Sri. Siddaraju.T.S. Son of
N.Siddalingaiah,
Aged about 63 years,
R/o. Siddalingeshwara Krupa,
5th Cross, Mahalakshminagar,
Batawadi, Tumakuru- 572 103. …….Complainant
(Smt. Navya B, Advocate.,)
V/s
-
Star Health and Allied Insurance
Company Limited,
Branch office at Shiva Complex,
-
K.R.Extension,Tumakuru-01. ………opposite party No.1
(Smt.Mamatha K.P, Advocate.,)
-
Narayana Hrudayalaya,
No.258/A, Bommanasandra,
Industrial Area, Anekal Taluk,
Bengaluru- 560 099.………opposite party No.2
(Sri. Deepak S Sarangmath, Advocate.,)
::O R D E R ::
SMT.NIVEDITA RAVISH, LADY MEMBER
This complaint filed by the complainant Under Section 35 of Consumer Protection Act, 2019 against the opposite parties to issue the direction to pay the amount of Rs.3,80,000/- with interest and to pay the compensation of Rs.5,00,000/-to the complainant towards the mental agony.
2. The OP.No.1 is the Manager, Star Health and Allied Insurance Company Limited, Tumakuru (herein after called as OP.No.1) and the Opposite Party No.2 is the Managing Director, Narayana Hrudalayala, Bengaluru ( herein after called as OP.No.2).
3. The case of the complainant is that, the complainant has availed a Insurance Policy from the OP.No.1 vide No.P/141131/01/2023/002879 and said policy was in force for the period from 16-09-2022 to 15-09-2023 covering all risk. The complainant was suffering from heart problem and admitted in the hospital of OP.No.2. The complainant has diagnosis that “Coronary Artery Disease double vassal disease normal RV and LV functions, LVEF- 60%. Diabetes mellitus Systemic Hypertension”. The complainant has informed the OP.No.2 about the insurance policy obtained by the OP.No.1 at the time of admission. But the hospital authority of OP.No.2 have insisted the complainant to deposit amount of Rs.3,80,000/-as package, accordingly the complainant has deposited the amount. Further OP.No.2 has submitted relevant documents to the OP.No.1 for claiming insurance amount pertaining to the complainant, but the OP.No.1 has send only Rs.1,00,000/- to the OP.No.2. The OP.No.2 has returned the same amount to the OP.No.1 without collecting and collected entire amount of Rs.3,80,000/- by the complaint. The complainant has approached the OP.No.1 in this regard, but the OP.No.1 has not obliged to settle the claim, even though the insurance was in force as on the date of treatment and on the other hand the OP.No.1 has told that the OP.No.2 has not submitted the paper and correct document for payment under the said insurance. Though the complaint got issued legal notice to the OP.No.1 and 2 on 18-11-2023, the OP.No.1 and 2 were not complied nor replied, hence this complaint.
4. After issuing of notice by this Commission, the OP No.1 and 2 are appeared before this Commission through their respective counsels and filed their versions.
5. In the version of OP.No.1, the OP.No.1 has admitted that the complainant has availed the Star Health Assurance Policy from OP.No.1. Further OP.No.1 has denied all other allegations made by the complainant as a false and submitted that, the complainant having diabetes, hypertension as a PED (Pre Existing Disease). Further OP.No.1 has submitted that, the complainant reported claim within six months of the medical insurance policy and the OP.No.1 has initially approved Rs.1,00,000/- on 26-06-2023 for cashless treatment of the complainant. But the complainant was not utilized the same. Hence same amount was rejected and withdrawing on 9-7-2023. Further OP.No.1 has submitted that, subsequently the complainant submitted the documents for reimbursement of his medical expenses for Rs.4,05,120/-. After the scrutiny of documents the query raised on 3-8-2023 to submit some other documents and the complainant has failed to produce the same documents. Hence the claim of the complainant was rejected and OP.No.1 has submitted that the complainant has not followed the terms and conditions of the policy. Hence there is no any deficiency on the part of the OP.No.1. Hence, prayed for dismissal of the complaint against OP.No.1 with cost.
6. The OP.No.2 has submitted in their version that, OP.No.2 is the hospital has no role in whether the OP.No.1 approves or disapproves the cashless insurance or fails to refund the hospitalization expenses of the complainant to refund the hospitalization expenses of the complainant. Hence the complaint against OP.No.2 is not maintainable and further submitted that, the complainant approached the OP.No.2 with a request for cashless hospitalization for the Surgical Management of his SCELEROTC AORTIC VALVE DOUBLE VESSLE DISEASE (DVD) AND accordingly a request for cashless hospitalization for Health Insurance of the complainant with his Policy No.P/141131/01/2023/002879 was submitted by the OP.No.2 with the signature of the complainant to the Op.No.1 portal for approval on 21-06-2023 and 22-06-2023.OP.No.1 has communicated to the OP.No.2 the denial of the Preauthorization Request for cashless treatment of complainant with note. But OP.No.2 again for the sake of the complainant requested the OP.No.1 for reconsideration of its decision denying the cashless treatment. However, the complainant wanted to get treated immediately and complete his CABG surgery and as per the instructions of the complainant himself, the complainant admitted to the OP.No.2 on 24-06-2023 by paying,
a) INR 2,00,000/- paid on 24-06-2023 at 12.45 p.m.
b) INR.1,70,450/- paid on 24-06-2023 at 12.51.p.m. and
c) INR.4,100/- paid on 27-06-2023 at 10.43 a.m.
Further OP.No.2 has submitted that, on the reconsideration request of the OP.No.2, the OP.No.1 approved a sum INR.1,00,000/-on 26-06-2023. But already the complainant has paid entire amount for his treatment and the complainant wanted to claim reimbursement of the insurance claim. Therefore on the wishes of the complainant, the OP.No.2 intimated the Op.No.1 for cancellation of the approved a sum of Rs.1,00,000/, Hence OP.No.2 has submitted that, there is no any deficiency of service on the part of the OP.No.2 and prayed for dismissal of the complaint against the OP.No.2 with cost.
7. The complainant filed his affidavit evidence with 7 (seven) documents which are marked as Ex.P-1 to Ex.P-7. One Sri. Manjunath T.L, Branch Manager has filed his affidavit evidence with twelve documents and which are marked as Ex.R-1 to Ex.R-12. One Dr.Nitin, Manjuanth has filed his affidavit evidence with ten documents and which are marked as ExR-1 to Ex.R-10 (OP.No.2 series)
8. We have heard the arguments of the counsel for the complainant, OP.1 and 2 with written arguments filed by the OP.No.1 and points would arise for determination as follows:
- Whether the complainant proves deficiency in service on the part of OP No 1 & OP No2?
- Is complainant is entitled to the relief sought for?
- Our findings on the aforesaid points are as under:
Point No.1: In the Partly Affirmative
Point No.2: As per final order for the below
:R E A S O N S:
10. Point No.1:-The counsel for the complainant has argued that, the complainant has availed the health insurance policy from OP.No.1 and OP.No.1 has also admitted the same. Annexure of Ex.P-4, copy of insurance policy produced by the complainant is reflecting details of health insurance policy as, Policy No:P/1411321/01/2023/002879, name of the complainant, Total premium Rs.46,081.00, period insurance from 16-09-2022 to mid night of 15-09-2023, policy term: 1 year, Basic Floater sum insured: Rs.10,00,000/- and other details. Further counsel for the complainant has contended that, the complainant admitted in the OP.No.2 Hospital and Diagnosed that, “Coronary Artery Disease double vessel disease normal RV and LV functions, LVEF-60% Diabetes mellitus systemic Hypertension”. Ex.P-6/copy of the consulting letter to operation issued by OP.No.2 and produced by the complainant establishing the same. Further counsel for the complainant has submitted that, the complainant has informed about health policy to OP.No.2 and OP.No.2 have insisted the complainant to deposit amount of Rs.3,80,000/- as package and authority of OP.No.2 has stated that the amount which is deposited by the complainant will be refunded after getting the information from OP.No.1. But the complainant has failed to produce any documents to show that, the OP.No.2 has insisted the complainant as per above arguments of the complainant counsel. In the same time, Ex.P-5/copy of cashless Authorization letter produced by the complainant is reflecting that, the OP.No.2 has proceeded the application/requested to the OP.No.1 for the cashless treatment of the complainant. Further counsel for the complainant has argued that, the OP.No.1 has send Rs.1,00,000/- to OP.No.2 after submitting the relevant documents by the OP.No.2. But the OP.No.2 has returned amount to OP.No.1 without collecting the same. Ex.P-7 and P-7(A)/copy of withdrawal of approval given earlier is reflecting that, the OP.No.2 has withdrawn the amount approved and it is reflecting that, OP.No.2 has informed OP.No.2 that, the insured has not utilized the amount approved by the OP.No.1 for cashless treatment. Further counsel for the complainant has argued that the complainant has approached the OP.No.1 with claim for reimbursement and same claim was repudiated by the OP.No.1 to prove the same, the complainant has produced Ex.P-4/copy of repudiation of claim dated:05-09-2023.
11. Per contra, counsel for the OP.No.1 has contended that, the complainant disclosed diabetes and hypertension in the proposal form. Hence, diabetes, hypertension and its complications are incorporated as PED(pre existing disease) Ex.R-1/copy of proposal form produced by OP.No.1 reflecting that, the complainant has disclosed about diabetes and hypertension. But, it is clearly establishing that the OP.No.1 has issued the policy to the complainant after declaring his health conditions to the OP.No.1. Further counsel for OP.No.1 has contended that, the complainant reported claim within six months of medical insurance policy, when there is exclusion clause for the Pre Existing Disease. Ex.R-2/copy of terms and conditions produced by OP.No.1 explaining about exclusions clause for pre existing disease under code Excl.01. Further counsel for the OP.No.1 has argued that, initially the OP.No.1 has approved Rs.1,00,000/- for cashless treatment on 26-06-2023. But the complainant has not utilized the same and same was rejected and withdrawn on 09-07-2023. Further, OP.No.1 has contended that, the complainant submitted the documents for reimbursement of his medical expenses for Rs.4,05,120/- and query was raised to submit the following details vide letter dated 03-08-2023.
a) Discharge summery of previous admissions/hospitalization.
b) Letter from treating doctor stating exact duration of CAD,
when was it first diagnosed.
c) Previous consultation papers, ECG, ECHO reports.
d) Previous hospitalization details of 2018. But the complainant has
failed to submit above documents hence the claim of the
complainant was rejected.
To prove the case, OP.No.1 has not produced the copy of the letter dated:03-08-2023 written to the complainant with query to submit the above documents. In the same time, the OP.No.1 himself has produced the copy of discharge summery of the complainant as Ex.R-9 and Ex.R-10, The Ex.R-9 produced by the OP.No.1 has reflecting that, procedure history-
- Angiogram, CAG-DVD DONE on 16/06/2023.
- Inguinal hernioplasty , RIGHT SIDE on 05/12/2018,
Ex.R-10 has clearly showing that, the complainant has taken treatment for Hernia on 05-12-2018 and taken treatment for heart issues on 16-06-2023, which are not inter connected treatments. Further Ex.P-6/copy of consulting letter issued by the OP.No.2 and produced by the complainant itself is establishing that, the complainant has suffers chest pain before two days from the date of admission of the complainant i.e., 16-06-2023.
12. Further counsel for the OP.No.1 has contended that, the complainant had consumed the Alcohol since from 30 years and smoking from 20 years and the code Excl.-12 of the policy denies to reimburse the claim of the complainant. Ex.R-12 produced by the OP.No.1 explains the code Excl-12 as “treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof” is excluded. On verifying the Ex.R-7/copy of consultation summary issued by the OP.No.2 and produced by the OP.No.1 has reflecting that, Social History –
–Duration 30 years –
Stopped since 10 days.
Duration – 20 years
The Ex.R-7 produced by the OP.No.1 has not establishing about in what quantity the complainant has consumed the alcohol and smoking. Further Ex.R-7 has not reflecting that, the OP.No.2 treating doctor has given opinion that, the alcohol and smoking are caused to the said heart problem of the complainant. Therefore, the contention of the OP.No.1 is not considered. Ex.R-2/copy of the policy pertaining to the complainant and produced by the OP.No.1, establishing that the period of insurance from 16-09-2022 14:09 at midnight 15-09-2023 and Ex.R-9/copy of discharge summary produced by the OP.No.1 reflecting that the complainant admitted for treatment on 16/06/2023 and discharged on 17-06-2023. Ex.R-10 reflecting that again complainant admitted on 24-06-2023 and discharged on 04-07-2023. Therefore it is reveals that, the policy was inforce at the time of treatment taken by the complainant.
13. Further Hon’ble Supreme Court in numerous judgment has observed that conditions like hypertension (Blood Pleasure) and diabetes are not diseases but common physical disorders and is no ground to deny rightful insurance money to patients and in Sunil Kumar Sharma V/s. TATA AIG Life Insurance Company and Others, bearing Case No. RP.No.3557/2013 decided on 01-03-2021 and in the case of Reliance Life Insurance Company Ltd, and Anr V/s. Tharun Kumar Sudhir Halder dated:31-05-2019, the Hon’ble National Consumer Commission, New Delhi was opinioned that, “the insurance claim cannot be denied on the ground of these life style disease that are so common . However, it does not give any right to the person insured to suppress informed in respect of such diseases”. Earlier the OP.No.1 has approved Rs.1,00,000/- for cashless treatment without any query and though there is no any violation of the terms and conditions by the complainant, the OP.No.1 has repudiated the claim of the complainant for reimbursement of the insurance. This act of the OP.No.1 is amounts to deficiency in service on the part of the OP.No.1.
14. Counsel for the OP.No.2 has argued that, the OP.No.2 has given proper treatment to the complainant and approve or disapprove the insurance claim is not the part of the OP.No.2. Further counsel for the OP.No.2 has submitted that, the complainant visited the OP.No.2 hospital on 14-06-2023 and again visited on 16-06-2023. After undergoing coronary Angiogram (CAG) test complainant was diagnosed with Double Vessel Disease- Coronary artery disease. Further, counsel for OP.No.2 has submitted that, the complainant was admitted on 16-06-2023 in the OP.No.2 hospital and discharged in stable condition on 17-06-2023 after CAG, but complainant has not opt any insurance for cashless treatment for the CAG. Again by following the discharge advise, the complainant came to OP.No.2 hospital for subsequent consultation on 21-06-2023 and the complainant advised Coronary Artery Bypass Grafting (CABG conics) surgery. Ex.R-2 (OP.No.2 series)/copy of consultation summery produced by the OP.No.2 establishing the same. Further counsel for OP.No.2 has submitted that the complainant asked for approximate costing for treatment and OP.No.2 has intimated the approximate cost would be INR 3,60,000/- towards treatment + INR 75,000 towards ICU charges and INR 6150/ per day room rent. Upon knowing of the above cost, the complainant asked for facility of cashless treatment. Accordingly, OP.No.2 has submitted the request for cashless treatment with OP.No.1 on 21-06-2023. Ex.R-3(OP.No.2 series)/copy of request letter establishing the same.
15. Further counsel for the OP.No.2 has contended that, on 22-06-2023, the O.No.1 communicated to the OP.No.2, the denial of Preauthorization request for cashless treatment of complainant. To prove the same, the OP.No.2 has produced the Ex.R-4(OP.No.2 series) COPY OF Denial of Preauthorization request for cashless treatment sent by the Op.No.1 on 22-06-2023 and the same Ex.R-4(OP.No.2 series) is reflecting the note as, “we have scrutinized your request for approval for cashless treatment of the above insured patient for diagnosed disease of SCLEROTIC AORTIC STENOSIS. We are not able to ascertain the duration of the disease based on the documents/details submitted by you. It requires further evaluation. Hence we deny the approval or cashless treatment of the above diagnosed disease. The insured may however submit the documents to us seeking reimbursement of expenses included relating to the treatment of the above disease. A letter addressed to the insured is attached. Please handover copy to the insured”. Further counsel for the OP.No.2 has submitted that, OP.No.2 on 22-06-2023 for the sake of the complainant requested the OP.No.1 for reconsideration of its decision denying the cashless treatment and provided further explanation to the query raised by the OP.No.2. Ex.R-5 (OP.No.2 series)/copy of reconsideration request for cashless treatment produced by the OP.No.2 establishing the same.
16. Further counsel for OP.No.2 submitted that, in the mean time the complainant wanted to get immediately admitted and complete his CABG surgery and as per instructions of the complainant himself, the complainant was admitted to OP.No.2 hospital on 24-06-2023 for the CABG surgery and paid the amount. To prove the same the OP.No.2 has produced the Ex.R-6, Ex.R-9 (OP.No.2 series) copy of receipt, bill and these are establishing that the complainant paid Rs.2,00,000/-, Rs.1,70,450/-on 24-06-2023 and paid Rs.4,100/- on 27-06-2023. Further counsel for the OP.No.2 has submitted that the OP.No.1 has approved a sum of Rs.1,00,000/- for the complainant vide its cashless authorization letter dated 26-06-2023, but the complainant has s wished not to utilize the cashless treatment when he had paid already Rs.3,70,000/- on 24-06-2023 and the complainant wanted to claim reimbursement of the total surgery sums from OP.No.1. Hence based on the complainant wishes OP.No.2 has intimated the OP.No.1 for cancellation of the approved a sum of Rs.1,00,000/- Ex.R-7(OP.No.2 series)/copy of authorization letter establishing that the OP.No.1 approved Rs.1,00,000/- for cashless treatment of the complainant on 26-06-2023 and Ex.R-8 (OP.No.2 series)/copy of cancellation letter dated 26-06-2023 establishing that, the OP.No.2 has send a letter to OP.No.1 for cancellation of approved amount for cashless treatment on the wishes of the complainant. The OP.No.2 has given treatment to the complainant after the denial of the cashless treatment by the OP.No.2 and send cancellation letter for approved amount on the wishes of the complainant. Hence, we have not found any allegations of deficiency in service on the part of the OP.No.2. Therefore the complaint against the OP.No.2 is liable to be dismissed.
17. The counsel for the complainant has prayed to direct to reimbursement the claim of the complainant by paying Rs.3,80,000/-. But Ex.R-6, copy of final bill produced by the OP.No.1 and issued by the OP.No.2 has reflecting amount paid by the complainant to OP.No.2 as Rs.3,74,549-65. On perusing Ex.R-12/copy of terms and condition of the policy produced by the OP.No.1 some benefits are not covered under the policy, those are Sl.No.6,42,46,50,113,123,128,179 under the head of surgical consumables in the Ex.R-6. The total amount of the above serial numbers are calculated as Rs.5,305/- and by reducing this amount in the final bill, it is worked out as Rs.3,69,244-65. Though there is policy in force and the complainant has provided the related/relevant documents to the OP.No.1, the OP.No.1 has repudiated the claim of the complainant. This act of the OP.No1 amounts to deficiency in service on the part of the OP.No.1. Hence OP.No.1 has liable to pay the Rs.3,69,244-65 with interest @ 8% p.a. from 05-09-2023 (i.e., date of repudiation of claim) till realization. Further the OP.No.1 has compelled the complainant to approach this Commission. Hence, the OP.No.1 has liable to pay Rs.8,000/- as a litigation cost to the complainant. The complainant has prayed to direct the opposite parties to pay Rs.5,00,000/- towards the compensation. But complainant has failed to produce any documents to show that he has eligible to get Rs.5,00,000/- as compensation. By considering the mental agony caused to the complainant, the OP.No.1 has liable to pay compensation of Rs.10,000/- to the complainant. Accordingly, we proceed to pass the following :-
:O R D E R:
The complaint filed by the complainant is partly allowed against OP No.1 with cost.
It is directed that the OP.No.1 shall pay Rs.3,69,244-65 with interest @ 8%.p.a. from 05-09-2023 till realization to the complainant.
Further it is directed that the OP.No.1 shall pay compensation of Rs.10,000/- and litigation cost of Rs.8,000/- to the complainant.
Further it is directed that the OP.No.1 shall comply the above order within the 45 days from the date of receipt/knowledge of this order.
The complaint against the OP.No.2 is dismissed.
