By. Sri. Jose. V. Thannikode, President:
The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to get the medical claim and to get cost and compensation due to the unfair trade practice and deficiency of service.
2. Brief of the complaint:- The complainant is the beneficiary of Senior Citizens Red Carpet Health Insurance policy issued by opposite party No.2 as per policy No.P/181314/01/2016/003862. The complainant is a senior citizen and opposite party No.1 approached the complainant and canvassed his and as the health insurance policy conducted by opposite party No.2. The 1st and 2nd opposite party assured the complainant that the Senior Citizens Red Carpet health insurance policy is different from other types of policies and it assures either the 100% reimbursement of hospital and other expenses or cash less treatment plus other expenses for all type of deceases and diagnosis, only condition is 24 hour hospitalization and as per the assurance opposite parties No.1 and 2 the complainant with great hope opted the above said policy and joined. The complainant was admitted in PUTHALATH eye Hospital, Kozhikode on 12.01.2017 for Cataract Treatment arid Phaco surgery was conducted by the hospital and treated therein as impatient and discharged on, 13-01-2017,the complainant has intimated the hospital admission to opposite party No.1 and 2 immediately after the admission and opposite patty No.2 has registered the claim as claim No.CLI/2017/181314/0371210 and opposite parties No.1and 2 have offered cashless treatment, the complainant has given the copies of bills to opposite party No.2 but against the policy conditions opposite party No.2 has not provided cash less treatment and the complainant was compelled to pay Rs.21,197/-as the hospital bill and spent Rs.4,000/- as Taxi fare. The complainant prior to the admission i. e. on 09-01-2017 itself informed the 1st and 2nd opposite parties about the treatment and the opposite parties assured the cashless treatment. and reimbursement of other expenses and by believing upon the words of opposite patties the complainant was admitted and treated in the hospital. The complainant after the discharge approached the opposite parties No.1 and 2 and they told the complainant that the claim was under process Mid the claim amount will be given by the 3rd opposite party in a week and after one week again complainant approached the opposite parties, but the opposite parties instead of payment rejected the claim of complainant without and Cause. The opposite parties has canvassed the complainant by offering cashless treatments and easy processes and behaving upon the words of opposite party the complainant has joined in 2nd opposite party's health insurance policy with great hope, but the opposite parties have committed unfair trade practices and wilfully cheated the complainant with ill motive. The opposite parties are interested ID profit only and the acts of opposite parties caused unlawful loss to complainant and opposite parties have gained unlawfully. The opposite parties has no right to repudiate the claim of complainant. The opposite party has the bounden duty to reimburse the hospital expenses and other expenses with compensation to complainant. The complainant as a last resort has send a lawyer notice to opposite party No.2 and 3 on 08-02-2017 with a demand to reimburse the hospital expenses and other expenses with compensation to the complainants, the opposite parties has received the notice but not replied to notice and no positive response was invoked by the notice The complainant now convinced that the opposite parties will not redress the grievance of complainant without recourse to legal steps. The complainant has witnesses and documentary evidences to prove the case. Hence filed this complaint.
3. Opposite parties notice served but opposite party No.1 is not appeared and not filed version, hence he is declared as ex-parte.
4. Brief version of opposite party No.3 and 4:- It is submitted that the complainant had taken the policy named Senior Citizens' Red Carpet Insurance Policy from this Opposite Parties for the period from 27-02-2016 to 26-02-2017 vide policy No.P/181314/01/2016/003862 for a sum insured of Rs.2,00,000/ -. At the time of availing the policy the complainant was supplied with the Terms and Conditions of the policy. The terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED". It is submitted that in case of Senior Citizen Red Carpet Insurance Policy medical examination is not required as the insured must be above 60 years of age. The policy is issued strictly according to the terms and conditions of the policy. The complainant herein had admitted the terms, conditions and exclusions set in the policy and thereafter had signed the proposal form of the policy. There was no deficiency in the service on the part of the opposite parties as the treatment taken by the complainant was within the period of one year from the date of inception of policy which is clear from the case records of the insured who underwent treatment at Puthalath Eye Hospital, Koizhikode. It is submitted the opposite party has received a pre-authorization request from Puthalath Eye Hospital, Kozhikode on 10.01.2017 for a planned admission at the hospital on 12.01.2017 and was provisionally diagnosed with ''Cataract both eyes''. Since the hospitalization was mainly for treatment of cataract, the opposite party rejected the claim based on Exclusion clause No.3(a) of the policy ie two year exclusion.
5. It is submitted that as per Exclusion Clause No.3 (a) of the policy, "During the first two years of continuous operation of insurance cover, the company is not liable to make any payment in respect of any expenses incurred by the insured person for treatment of Cataract, Glaucoma, Diseases of the anterior segment and posterior segment of the eyes, All diseases related to ENT, Diseases related to Thyroid, Prolapse of invertebral disc (other than caused by an accident), varicose veins and varicose ulcers, all diseases of Prostrate, Structural Urethra, all types of Hernia, Varicocele, Fistulal Fissure in ano, Hemorrhoids, Pilonidal Sinus and Fistula, Rectal Prolapse, Stress Incontinence and Congenital Internal diseasel defect." Hence the opposite party had rejected the pre-authorization for cashless treatment and has informed the hospital on 10.01.2017. It is submitted that there is no deficiency in service from the part of this opposite party. The claim was repudiated based on the terms & conditions of the policy. The complainant had taken the policy only on 27-02-2016 and had undergone treatment on 12-01-2017 which is within one year of inception of the policy. The allegations in paragraph 1 and 2 of the complaint are not fully correct and are denied. The allegation of the complainant that the opposite party No.1 approached the complainant and canvassed him and as per the advice and direction of opposite party No.1 the complainant joined in the health insurance policy are baseless, bereft of truth and are denied. It is submitted that the complainant had approached the 1st opposite party for taking the policy. thus the 1st opposite party had explained all the conditions of the policy to the complainant. The complainant after fully understanding and knowing with terms and conditions of the policy had accepted the same. The allegation of the complainant that the opposite parties 1 and 2 had assured that the Senior Citizen Red carpet Policy is different from other policies and assures 100% reimbursement of hospital and other expenses or cashless treatment plus other expenses for all type of diseases and diagnosis is absolutely wrong .and all are made only for the purpose of this case and only to mislead this Hon'ble Forum. As submitted earlier, the particular illness, ie, "Cataract" comes under the exclusion clause and it has been specifically explained to the complainant by the opposite party 1 and 2 before issuance of the policy. The allegations in paragraph 3 of the complaint are not fully correct and are denied. The allegation of the complainant that after discharge he had approached opposite party 1 and 2 and they had assured that the claim amount will be given within one week are all baseless and are denied. No such assurance was ever given by the opposite parties. The complainant had not submitted any medical bills to the opposite party after the discharge. It is further submitted that the complainant had not submitted any claim with documents or bills to these opposite parties at any point of time.
6. The allegations in paragraph 4 of the complaint is baseless, bereft of truth and are denied. There has been any unfair trade practice from the part of the opposite party. The opposite party has acted as per the terms and conditions of the policy as per the instruction of IRDA. The opposite party had every right to repudiate the claim of the complainant as the treatment undergone by the complainant is excluded for the first two years under the policy. The opposite party is not bound to reimburse the hospital expense and other expense with compensation to the complainant. The allegations in paragraph 5 of the complaint are not correct and are denied. The opposite party had received a lawyer notice dated 08.02.2017 and the opposite party had duly replied to the same on 09.03.2017. There is s no deficiency in service or unfair trade practice from the side of opposite party. The complainant is not entitled to any of the reliefs prayed for. The complainant is not entitled to the cost and compensation from this opposite parties, it is the opposite parties who are eligible for the cost and compensation from the complainant. The preamble of the policy contract clearly states that liability under the insurance policy is subject to terms, conditions, exclusions & definitions. Moreover in the policy schedule, it was recorded that the insurance under the policy is subject to conditions, clauses, warranties, exclusions etc & the same was issued to the complainant. It is a settled law that terms of the policy have to be construed as it is and the court cannot add or subtract something beyond the policy terms & conditions. The complainant has filed this complaint vexatiously and frivolously for the sole purpose of harassing the opposite parties with the intention for getting unlawful enrichment from the opposite parties who are dealing with public money and functioning under the guidelines of IRDA controlled by the Government of India. As public money is held in trust, the company must exercise abundant caution in dealing with the claims by applying all conditions correctly. It is humbly submitted from the above facts and submission that there is no deficiency of service on the part of the opposite party. The opposite party is entitled to get compensatory cost from the complainant for the reason that the complainant dragged the opposite party in to an unnecessary litigation knowing fully well that his treatment falls under exclusions as per policy. Therefore compensatory cost may be allowed. In view of the above facts and submissions this Hon'ble Forum be pleased to dismiss the complaint and allow cost and compensation the Opposite party and tender justice .
7. Complainant filed proof affidavit and stated as stated in the complaint and he is examined as PW1 and Ext.A1 to A6 documents were marked. Ext.A1 is the Senior Citizens Red Carpet Health Insurance policy. Ext.A2 series are the bills issued by Eye Hospital. Ext.A3 series are the Tourist Taxi Receipts. Ext.A4 is the Discharge Summary report. Ext.A5 is the Rejection of Pre-authorization for cashless treatment. Ext.A6 series are the Postal Receipts and Lawyer Notice issued to opposite parties.
8. Opposite parties also filed proof affidavit and he is examined as OPW1 and Ext.B1 to B5 documents were marked with subject to proof. Ext.B1 is the Proposal form for Senior Citizens Red Carpet Health Insurance Policy. Ext.B2 is the Policy Schedule. Ext.B3 is the Request for cashless hospital expenses. Ext.B4 is the Rejection of Pre-authorization for cashless treatment. Ext.B5 is the Registered Reply notice for lawyer notice.
9. On considering the complaint, version and evidences the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service or unfair trade practice from the part
of opposite parties?
2. Relief and Cost.
10. Point No.1:- The complainant took a Senior Senior Citizens Red Carpet Health Insurance Policy from the opposite party and the period is from 27.02.2016 to 26.02.2017. Along with policy Certificate no condition and clauses were attached. Ext.A2 series shows the treatment expenses of Rs.21,257/- spend by the complainant. Ext.A3 and A4 shows an expense of Rs.4,000/- incurred by the complainant for traveling. Ext.A4 proves the treatment. Ext.A5 is the Rejection of pre-authorization for cashless treatment, wherein it is noted that the patient has been diagnosed with CATARACT. As per exclusion No.3 of the policy such claim are not admissible but it is not proved by the opposite party that the condition and clause were supplied to the complainant. The produced documents by the opposite party is marked subject to proof and thereafter it is not proved also.
11. Hence we are of the opinion that canvasing the complainant after offering cashless benefit and treatment and rejecting the claim stating untenable objection is a clear case of unfair trade practice and deficiency of service from the side of opposite parties. Hence the Point No.1 is found accordingly.
12. Point No.2:- Since the Point No.1 is found against the opposite parties, opposite parties are jointly and severally liable to pay the treatment expenses with interest and also liable to pay cost and compensation to the complainant and the complainant is entitled for the same.
In the result, the complaint is partly allowed and opposite parties are jointly and severally directed to pay Rs.21,197/- (Rupees Twenty One Thousand One Hundred and Ninety Seven) which is the claim amount with 12% interest from 12.01.2017 and also directed to pay Rs.5,000/- (Rupees Five Thousand) as compensation and Rs.2,500/- (Rupees Two Thousand and Five Hundred) as cost of the proceedings to the complainant within one month from the date of receipt of this Order. Failing which the complainant is entitled for an interest at the rate of 12% for whole amount till realization.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 22nd day of September 2017.
Date of Filing: 18.03.2017.
PRESIDENT :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Gangadharan. Photostat Shop.
Witness for the Opposite Parties:-
OPW1. Balu. Executive legal, Star Health.
Exhibits for the complainant:
A1. Senior Citizens Red Carpet Health Insurance Policy Schedule for the period
27.02.2016 to 26.02.2017.
A2. Bills (5 Numbers).
A3. Tourist Taxi Receipts (2 numbers).
A4. Discharge Summary Report.
A5. Rejection of Pre-authorization for Cashless Treatment. Dt:10.01.2017.
A6(Series). Lawyer Notice and Postal Receipt.
Exhibits for the opposite parties:-
B1. Copy of Proposal Form for Senior Citizens Red Carpet Insurance Policy.
B2. Copy of Senior Citizens Red Carpet Health Insurance Policy Schedule for the period
27.02.2016 to 26.02.2017.
B3. Copy of Request for Cashless Hospitalization For Medical Insurance Policy.
B4. Copy of Rejection of Pre-authorization for Cashless Treatment. Dt:10.01.2017.
B5. Copy of Reply Notice. Dt:09.03.2017.
Sd/-
PRESIDENT, CDRF, WAYANAD.
a/-
