Chandigarh

DF-I

CC/946/2019

Vishal Pahariya - Complainant(s)

Versus

M/s Aditya Birla Health Insurance Co. Ltd. - Opp.Party(s)

Surjeet Bhadu, Abhinav Kansal & Veer Singh

03 Feb 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/946/2019
Date of Institution	:	18.9.2019
Date of Decision	:	03.02.2023

 

Vishal Pahariya S/o Ramesh Jain residing at house No.3014, Sector 27D, Chandigarh.

.

… Complainant

V E R S U S

1. M/s Aditya Birla Health Insurance Company Limited through its Branch Incharge and having its Branch office at SCO 2473, First floor Sector 22-C, Chandigarh 160022.
2. M/s Aditya Birla Health Insurance Company Limited 9^th floor, one Indiabulls centre Tower-I, Jupiter Mill Compound, S.B. marg Elphinstone Road, Mumbai Maharashtra 400013, through its authorized signatory.
3. M/s Edelweiss Insurance Brokers Ltd. Having its office at Unit No.1201&1202, 12^th floor, C-Wing, Godrej Coliseum, Everard Nagar, Sion (E), Mumbai, Maharashtra 400022 through its Director Sh. Anurag Madan (DIN 00010324).
4. Vidal Healthcare TPA Ltd. Having office at 1^st floor, Tower 2, SJR iPark, EPIP  Zone, Whitefield Banglore, Karnatka 560066. Through its Director Girish  Rao (DIN 00073937)
5. M/s Jain International Organization through its Chairman/Presiding officer and having its office at Panchsheel Plaza, A wing basement, Near Dharam Palace, Hughes Road, Mumbai, Maharashtra 400007.

 .  … Opposite Parties

 

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

                        

ARGUED BY	None for the complainant.
	Ms. Nidhika Luthra, Advocate proxy for Sh. Nitin Thatai, Adv. For Ops No.1&2. None for OP No.3. Op No. 4 exparte. None for No.5

Per surjeet kaur, Member

1. Briefly stated, the complainant purchased top up policy through JIO having super top up of Rs.10,00,000/- with base limit of Rs.3.00 lakh  (beyond three lacs the claim was payable under top up insurance policy upto 10.00 lakh) by paying premium of Rs.16,983/- online  to JIO which was further paid by JIO to OP No.1. The start date of the policy was 1.4.2018. It is stated that the base policy is necessary for the top policy and the complainant purchased the base insurance policy from JIO which is provided by Star Health and Allied Insurance Company Ltd. With a limit upto Rs.10,00,000/-. During the insured period the complainant got admitted on 20.4.2018 at the N.M. Virani Wockhardt Hospital in Rajkot Gujarat for treatment of Acute Enteritis, Hypophosphatemia osteomalacia, IBD  and was discharged on 21.4.2018. The hospital applied for cashless treatment with base mediclaim insurance policy i.e. Start Health and Allied Insurance Co. Ltd., which sanctioned amount of Rs.5,06,005/- from the base insurance policy.  The complainant again admitted in hospital for the same medical problem  on 17.8.2018 and was discharged on 18.8.2018. Again the hospital applied for cashless treatment with base mediclaim insurance policy the Star Health Insurance sanctioned amount of Rs.3,71,155/-  from the base insurance policy out of the total bill of Rs.6,78,779/-  and OP No.1 reimbursed Rs.3,05,512/- under the super top up insurance policy without any demure or dispute. The complainant was again admitted for treatment of the same disease on 13.12.2018 and discharged on 14.12.2018 and a bill of Rs.4.00 lakh was raised by the bill. It is alleged that the OP No.1 did not pay the bill amount to the hospital and as such the complainant had to pay the bill from his own pocket. Thereafter the complainant filed claim with OP OP.1 under the super top up policy on 31.12.2018 and sent various communications for settlement of his claim but the OP No.3 the third party administrator on behalf of insurance company vide email dated 21.2.2019 informed the complainant that the claim is rejected on the ground that INJ Entyvio is not payable in day care procedure. However on contrary to the reason mentioned in email there is an attachment letter dated 14.1.2019 wherein it has been given a totally different reason for rejection of the insurance claim that the claim is rejected because the covered  hospitalization expenses do not exceed the threshold limit opted for the insured person, hence, there can be no claim under the top of policy. It is alleged that the treatment bill on the face of it shows that the same is much more than 3 lakh and the condition of super top up policy that the insured was required to take a base policy for Rs.3.00 lakhs which will cover base expenses. It is alleged that the other ground for rejection of the claim of the complainant is also baseless and frivolous. 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 admitted that the complainant was admitted for treatment of Acute Enteritis, Hypo-Phosphatemia Osteomalacia, IBD on 13.12.2018 and discharged on 14.12.2018. The complainant filed his claim of Rs.4.00 lakh under the top up policy on 31.12.2018. However, since the complainant had selected a deductible amount of Rs.3.00 lakhs while purchasing the policy, the claim becomes payable once the aggregate payable claim amount exceeds the deductible amount. The payable claim amount in the instant case was calculated after deducting the charges of injection entyvio and other pharmacy from the bill amount and the final amount did not exceed the deductible of Rs.3.00 lakhs, hence, the claim of the complainant was denied by the answering OPs based on the terms and conditions of the policy and the same was communicated to the complainant vide repudiation letter dated 12.1.2019. It is denied that there is any deficiency on the part of the answering OPs.  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 the complainant availed the insurance from Aditya Birla Health Insurance Company Ltd. who alone is liable to decide the claim of the complainant. It is averred that the complainant has paid premium for insurance to the Ops No.1&2 through OP No.5 and not to the OP No.3 and as such the answering OP No.3 is not liable to pay any amount to the complainant. Denying all allegation made in the complaint against the answering OP a prayer for dismissal of the complaint has been made.   
4. OP No.5 in its reply stated that the answering OP is a religious charitable institution registered under Society Act.  The answering OP has not charged from the complainant except JIO Membership fees called as JIO-JAC fees for providing any commercial services and therefore, the complaint is not maintainable against it. It is admitted that the OPs No.1&2 received premium amount through the answering OP. It is stated that the answering OP is only a facilitator and not insurer. It averred that there is no deficiency on the part of the answering OP.
5.    OP No.4 did not turn up despite due service of notice, hence Opposite Party No.4 was proceeded exparte vide order dated  5.12.2019.
6.  Rejoinder was filed and averments made in the consumer complaint were reiterated.
7. Contesting parties led evidence by way of affidavits and documents.
8. We have heard the learned counsel for the contesting parties and gone through the record of the case.
9. The sole grouse of the complainant in the present complaint is that his genuine claim of Rs.4.00 lakh under the policy in question was denied by the OPs without any valid reasons.
10. The stand taken by Ops is that as per repudiation letter Annexure C-13 the claim of the  complainant was rejected for the reasons as the covered hospitalization expenses do not exceed the Threshold limit opted for the insured person/family. Hence there can be no claim under the top up medicare policy. Also the same was rejected as deductible sum insured limit not crossed. On the other hand OPs No.1&2 in their written statement taken another stand that the claim amount was calculated after deducting the charges for injection entyvio and other pharmacy expenses from the bill amount.
11. After going through the evidence on record it is evident that the policy in question is valid from 31.3.2018 to 30.3.2019 namely Jio Super Top Up Medi claim policy for a sum of Rs.10.00 lakh with deductible base limit as Rs.3 lakh (aggregate of all claims in the year). Meaning thereby the policy dispute was to trigger after the complainant has paid Rs.3.00 lakh (base limit) from other insurance or from his own pocket. In April 2018 when the complainant got sick and Rs.5,06,005/- was paid by another insurance company i.e. M/s Star Health, thus, the base limit of Rs.3.00 lakh was crossed. Further again when the complainant got admitted in the hospital in August 2018 for the same disease a bill of Rs.6,78,779/- was raised by the hospital and out of the said amount M/s Star Health paid Rs.3,17,155/- and the OP No.1 paid Rs.3,05,512/- under the same policy and the said fact has not been denied by it but the claim in dispute  to the tune of Rs.4.00 lakh  under the  Super Top Up Policy  raised in December 2018 was refused by the OP No.1.  The Rejection letter sent by OP No. 1&2 annexed with the written statement of Ops No.1&2 at page 53 Annexure C states the reason for rejection as under:-

“You have selected a deductible amount of 3 lacs while purchasing your policy. Hence, your will be eligible to claim only once your claim amounts exceed this deductible amount. As per the claim submitted by you, the bill amount is less than your specified deductible amount. Hence this not eligible for claims.”

12. As the said limit crossed in April 2018 itself when the complainant availed a claim of base limit of Rs.5,06,005/-  from Star Health  the another insurance company, therefore, in our opinion the stand of OP No.1 that the base limit is not crossed is contrary to the facts and record. OP No.1 itself has sanctioned claim amount of Rs.3,05,512/- in August 2018 under the same policy for the same insurance year  and for the same disease and treatment. Thus, it is clear that OP No.1 has triggered the present policy after considering that the base limit has already crossed.
13. A perusal of Annexure C-1 at page 30 under clause 25 of the policy it is clearly mentioned that deductible limit will be calculated by adding all claims by family on one or more occasions, therefore, the deductible limit of 3 lakhs was already crossed in April 2018 in the instant case. Notably the OPs No.1&2 has taken entirely different stand in their written statement, which is nowhere mentioned in the repudiation letter that the claim of injection entivio (a type of medicine given to the complainant) was deducted from the claim amount. Thus the same has no merit. 
14.  Pertinently in August 2018 OP No.1 itself has sanctioned claim for the same medicine  to the complainant and as per terms and conditions of the policy Annexure A at page 22 of the written statement of Ops No.1&2 at Sr. No.6 it is clearly mentioned that medicines, drugs etc. prescribed by treating doctor shall be allowed under the policy. Moreover, the OPs No.1&2 has not shown any term of the policy to exclude injection entivio. It is also admitted fact that the complainant got admitted in hospital on 13.12.2018 and discharged on 14.12.2018. Thus, we are of the opinion that all the medicine administered during the admission in the hospital are duly covered by the policy in question, but the OPs No.1&2 wrongly denied the genuine claim of the complainant. Thus, deficiency on the part of the OPs No.1&2  is proved for not honouring the terms and conditions of their own policy and for that they are liable to compensate the complainant.  
15. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed against OPs No.1&2. OPs No.1&2 are directed as under:-

1. to pay the claim amount of Rs.4.00 lakh to the complainant with interest from the date of repudiation of the claim till realization.  
2. to pay 30,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay 10,000/- to the complainant as costs of litigation.

16.      This order be complied with by the OPs No.1&2 within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
17. Complaint against rest of the OPs stands dismissed.  
18.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

			Sd/-
			[Pawanjit Singh]
			President
			Sd/-
			[Surjeet Kaur] Member   Sd/-
			[Suresh Kumar Sardana]
mp			Member