Chandigarh

DF-I

CC/405/2023

MANOJ KUMAR - Complainant(s)

Versus

MANAGING DIRECTOR, STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED - Opp.Party(s)

Ridhi Sachdeva Adv.

30 Oct 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/405/2023
Date of Institution	:	22/08/2023
Date of Decision	:	30/10/2024

 

Manoj Kumar age 38 years son of late Mohinder Singh resident of House No.695, BSNL Colony, Sector 44-A, Chandigarh.

….Complainant

VERSUS

 

1. Managing Director M/s Star Health and Allied Insurance Company Limited, REGD. AND CORPORATE OFFICE: 1, NEW TANK STREET, VALLUVAR KOTTAM HIGH ROAD, NUNGAMBAKKM, CHANNAΙ-600034.

2.  M/s Star Health and Allied Insurance Company Limited, 2nd floor, SCO-5A, Sector-7, Chandigarh-160019.

3. IVY Hospital A unit of IVY Health and Life Sciences (P) Ltd. Regd. Administration block, IVY Hospital, Sector 71, SAS Nagar Mohali-160071.

..... Opposite parties

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR SURESH KUMAR SARDANA	MEMBER MEMBER

                       

ARGUED BY	:	Sh.Shekhar Chaudhary, Adv. for Complainant.
	:	Sh.Chetan Gupta, Adv. proxy for Sh.Inderjit Singh, Adv. for OP No.1 & 2.
	:	Sh.Sukhvir Verma, Adv. proxy for Sh.Pradeep Sharma, Adv. for OP No.3.

Per surjeet kaur, Member

     Briefly stated the complainant availed family floater policy from OP insurance company valid w.e.f. 24.3.2022 to 23.3.2023 having sum assured to the tune of Rs.5,00,000/- by paying premium of Rs.11,328/-.The mother of the complainant was suffering from severe knee pain and complainant got her check up done from OP No.3 which is empanelled hospital of the OPs NO.1 and 2. The doctor advised for complete knee replacement and on his advice the complainant got his mother admitted in the IVY Hospital for surgery. On 27.10.2022 and operated on 28.10.2022 and was discharged was on 01.11.2022. The total bill of Rs.349062/- was raised by Opposite Party No.3 and out of this amount Rs.61202/- was deducted on account of other deductions and some of Rs.28554/- was deducted as discount. After deductions the total amount of
Rs.259306/- was paid by the Opposite Party No.1 and 2 to Opposite Party No.3 1.e. IVY hospital.
The complainant being a member of employees association had availed the cashless policy and at the time of raising the final bill the IVY hospital deducted amount of discount and Rs.61202/- Rs.28554/- on account as of other deductions. These two amounts were illegally claimed from complainant and he was forced to pay the same by the Op NO.3. Complainant many times requested firstly the OP No.3/IVY hospital to waive off the discount amount but they did not do so and informed him that the OP No.1 and 2/insurance company would pay this amount to him. Complainant raised this issue with the OP NO.1 and 2 and then he was informed that since the OP No.3/IVY hospital has given the discount and thus they are liable for the same. As per policy post hospitalization of sixty days is included in insurance and therefore, the complainant separately claimed an amount Rs.59025/- out of which a Rs. 28907/- was on account of medicine and sum of Rs.18600/- was on account of physiotherapy and the rest amount was on account apparatus. But the OP insurance company refunded only a sum of
Rs.25000/- only to complainant and in this manner the OPs insurance company did not refunded Rs.1,12,283/- to the complainant. When the grievance of the complainant was not redressed the complainant sent legal notice dated 27.3.2023 but to no avail. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed.

2. The Opposite Parties NO.1&2 in their reply while admitting the factual matrix of the case stated that

the complainant has already received admissible claim amount by way of cashless treatment & an admissible amount to the tune of Rs. 259306/- has already been paid to the IVY Hospital, Mohali in accordance with policy terms and conditions against the billed amount of Rs. 3,49,062/- incurred for the hospitalization Kashmira Devi in IVY Hospital, Mohali for the period 27.10.2022 to 01.11.2022. Thereafter, complainant submitted the claim form for reimbursement for an amount of Pre/post Hospitalization treatment to the tune of Rs.59025/- out of which an amount of
Rs.25000/- was found payable and accordingly same was paid to the complainant. The claim of the complainant has been duly settled with full and final discharge of claim liability of answering opposite parties. the excessive bill claimed by the complainant  is beyond policy terms. Thus, the complainant is not entitled for any claim and complaint is liable to be dismissed. All other allegations made in the complaint has been denied being wrong.

3. OP No.3 in its reply stated that the complaint is not maintainable against it as there is no grievance against the OP No.3 in respect of medical treatment and grievance of the complainant is only against OP No.1&2 the insurance company for making deductions in the payment of claimed amount. Denying any deficiency on its part a prayer for dismissal of the complaint has been made.  
4. No rejoinder filed.
5. Contesting parties led evidence by way of affidavits and documents.
6. We have heard the learned counsel for the contesting parties and gone through the record of the case.
7. As per the case of the complainant, the OPs have illegally deducted amount of Rs.89776/- and Rs.22507/- on account of terms and conditions of the policy and hence, through present complaint, complainant seeking refund of the same alongwith compensation and cost of litigation.
8. Perusal of written statement filed by the OP No.1 & 2 reveals that the deduction reasons have been mentioned alongwith deducted amount. Pertinently, there is one discount at Sr. No.4 with mention as network hospital discount to the tune of Rs.28554/- but the OP No.1 & 2 have not shown any terms and conditions according to which the aforesaid amount is deductable. Moreso, the OP No.3 IVY Hospital has clearly stated that total bill raised was Rs.349062/- out of which amount of Rs.61202/- was deducted by OP No.1 & 2, the insurance company towards the admissible deductions and Rs.28554/- was deducted as discount. Interestingly, there is no mention of any discount of Rs.28554/- over the bill and as per OP No.3 there is no provision of applying the discount. Hence, in our opinion the deduction in the name of hospital discount is illegal and arbitrary and certainly a self created formula of OP No.1 & 2 the insurance complany.
9. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OP No.1 & 2 are directed as under:-

1. to pay ₹28554/- to the complainant alongwith interest @ 9% per annum (simple) from the date of filing of this complaint onwards.
2. to pay ₹10,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

10. This order be complied with by the OP No.1 & 2 jointly and severally within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount(s) mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
11. The consumer complaint qua OP No.3 stands dismissed with no order as to costs.
12. Pending miscellaneous application(s), if any, also stands disposed off.
13.  Certified copies of this order be sent to the parties free of charge. The file be consigned.

			[Pawanjit Singh]
			President
			[Surjeet Kaur] Member
30/10/2024			[Suresh Kumar Sardana]
ls			Member