Sri B.NARAYANAPPA,

     President

1. The complainant Sri. R. Venumadhav, Mysuru has filed this complaint against the opposite party The Manager, Star Health and Allied Insurance Company Ltd., Mysore praying to direct the opposite party to reimburse of unpaid medical expenses of Rs.45,271/- and Rs.45,000/- towards Philips Respironics Oxygen Concentrator prescribed by attending doctor to complainant.

2. The brief facts are that:-

The mother of the complainant was insured under policy from the year 2010.She was hale and healthy at the time of subscribing the policy and she was not under any medicationnor under any medical treatment and she never suppressed or hide anything from opposite party company regarding her health and she was not suffering from any pre-existing diseases prior to medical policy with the opposite party.

3.      The mother of the complainant  fell ill on 02.10.2019 and suffered Breathlessness, Fatigue, Low Oxygen Saturation, Cough and Sputum production and she was admitted to JSS Hospital, Mysore as inpatient from 02.10.2019 to 09.10.2019 and she was successfully treated and discharged and she incurred medical expenses of Rs.70,188/-.  The complainant submitted claim to opposite party.  The opposite party made part payment of Rs.24,917/- to Hospital Authorities and denied to make good the balance amount.  It is further contended that the opposite party has issued a statement which is not based on actual facts and figures on which the deductions have been made from the total bill amount issued by the hospital.  The complainant subscribed this policy in the good hope and anticipation that it will be helpful in case of any medical expenses in future.  The opposite party by not settling the portion of the medical expenses of the insured has caused mental agony and hardship.  Therefore the complainant was compelled to pay medical expenses which is nothing but deficiency of service on the part of opposite party which caused mental trauma to the complainant.  The complainant visited opposite party office, Mysore many times seeking reimbursement but opposite party rejected reimbursement claim which is against the settled principles of law.  Hence, this complaint.

4.  After   registration of this complaint, notice was ordered to be issued to opposite party.  In response to notice the opposite party appeared through its counsel and has filed version.  Contending  that the complaint is not maintainable either in law or on facts and  same is liable to be dismissed and admits that the complainant has availed Senior Citizen Red Carpet mediclaim insurance policy for his mother Smt. Kapila Rao A.S. for the sum assured of Rs.1,00,000/-vide policy  No. P/141116/01/2010 /003268 for the period from 16.02.2010 to 15.02.2011 and further it was renewed from time to time and lastly it was from 20.02.2018 to 19.02.2019 and further contended that the insured has raised the claim in the 10^th year of the medical insurance policy No.P/141116/01/2018/008114  for the period from 20.02.2018 to 19.02.2019.  The mother of the complainant was admitted to JSS Hospital, Mysore and diagnosed Acute Excaberation of COPD and raised pre-authorization request to avail cashless facility.  Based on the available  documents an amount of Rs.24,917/- was paid to the treating hospital vide NEFT dated 22.10.2019 by deducting some deductions as mentioned at para 4 a, b, c, d, e, of the version and contended that as per the condition No.5 of the policy,  a portion of  every admissible claim is to be borne by the policy holder i.e., 50% of each and every claim arising out of pre-existing diseases.  Hence, from the gross amount of Rs.50,835/- 50% co-payment has been applied and deducted Rs.25,417/-.  Thus an amount of Rs.44,770/- was deducted in total (i.e., Rs.19,353/- was deducted towards deductibles and Rs.25,417/- was deducted towards 50% of Co-pay) and  further submitted that the insured patient is a known case of COPD since 10 years.  The pre-existing disease was not declared in the proposal form.  Therefore claim was settled under 50% of the Co-Pay.  It is further contended that the opposite party has explained the terms and conditions of the policy to the complainant at the time of proposing the policy the claim of the complainant is not genuine there is no deficiency in service on the part of the opposite party and the complainant is not come to this Forum with clean hand and it is doubtful.  For all these reasons prays to dismiss the complaint.

5. The complainant in order to prove his case has filed his affidavit by way of examination in chief and the same was taken as P.W.1 and got marked documents Exhibit P1 to P6.  On the other hand the opposite party has also filed its affidavit by way of examination in chief and the same was taken as R.W.1 but not got marked any documents.  

6. We have heard the arguments of both sides.  The complainant has also filed his written arguments.  The opposite party not filed any written arguments.

7. The points that would arise for our consideration are as under:-  

1. Whether the complainant proves that the act of opposite party in settling partial claim of the complainant and without settling the full claim of the complainant is amounts to deficiency in service?
2.  What order?

8.       Our findings on the aforesaid points are as follows:

       Point No.1 :- Partly in the affirmative;

      Point No.2 :- As per final order for the following

:: R E A S O N S ::

9.        Point No.1:- The learned counsel for the complainant has vehemently argued   as per the contention taken in the complaint, affidavit of complainant and documents produced by the complainant and as per the notes of arguments.

10.      On the other hand learned counsel for opposite party has also vehemently argued as per  the contention taken in the version  and submits that as per the terms and conditions of the policy the opposite party has settled the admissible amount to complainant.  Hence, there is no merits in the complaint.

11.      We have perused the records, averments made in the complaint, affidavit of the complainant and documents produced by the complainant and taken note of arguments and also the affidavit of opposite party.

12.      It is not in dispute that the complainant has taken Senior Citizens Red Carpet Health Insurance Policy  for Rs.1,00,000/- to his mother vide policy No.P/141116/01/2019/005604 from 20.02.2019 to 19.02.2020 and it is not in dispute that mother of the complainant was insured under the policy from the year 2010 and the same was renewed from time to time and the same was valid from 20.02.2019 to 19.02.2020 and it is the specific contention of the complainant that at the time of inception of the policy her mother was hale and healthy and not suffering from any disease including any pre-existing disease.  The opposite party has also admitted that it had issued the policy No.P-141116/01/2010/003268  for the period from 16.02.2010 to 15.02.21011 and it was lastly renewed from 20.02.2018 to 19.02.2019 and contended that the complainant was the policy holder for his mother continuously for a period of 10 years and also admitted that on 02.10.2019 the mother of the complainant admitted to JSS Hospital, Mysore and she was diagnosed as COPD and requested to avail cashless facility based on the available documents, the opposite party paid a sum of Rs.24,917/- on 22.10.2019 and contended that at the time of inception of the mediclaim policy the complainant not disclosed the pre-existing disease of his mother and suppressed the said fact.  Therefore the amount of Rs.44,770/- was deducted in total (i.e., 19,353/- was deducted towards deductibles and Rs.25,417/- was deducted towards 50% of Co-Pay) and was paid Rs.24,917/- which was admissible.

13.      It is the specific contention of the complainant that at the time of inception of the policy about 10 years back the mother of the complainant was hale and healthy and she was not suffering from any pre-existing disease and not suppressed anything with regard to disease of the mother of the complainant.  Therefore the complainant has denied  the contention of the opposite party that the mother of the complainant was suffering from pre-existing disease called COPD as such out of gross amount of Rs.50,835/- (-) 50% Co-Pay has been applied and deducted Rs.25,417/-.

14.      The contention taken by the opposite party that the mother of the complainant was suffering from COPD therefore 50% of Co-Pay has been applied and deducted from Rs.25,417/- and paid Rs.24,917/- to the hospital was not correct since according to the version of the opposite party, the complainant was the policy holder for his mother for the last 10 years and continuously for the period of 10 years Senior Citizens Red Carpet Health Insurance Policy for Rs.1,00,000/- for the mother of the complainant has been renewed from time to time by the opposite party at the 10^th year the mother of the complainant admitted to JSS Hospital, Mysore for treatment from 02.10.2019 to 09.10.2019 as she was suffering from Breathlessness,, Fatigue,, Low Oxygen Saturation, Cough and Sputum Production etc., and she successfully treated and discharged and incurred medical expenses of Rs.70,188/- out of that the opposite party had paid only Rs.24,917/- but denied the balance amount.  Therefore the complainant come up with this complaint.

15.   Admittedly the complainant was the insured and holder of Senior Citizens Red Carpet Health Insurance Policy of Rs.1,00,000/- for his mother for continuous period of 10 years and the said  policy was renewed from time to time for a period of 10 years at the 10^th year the mother of the complainant due to some health issues admitted to hospital on 02.10.2019 to 09.10.2019 and she was treated successfully and discharged and incurred medical expenses of Rs.70,188/-, but the opposite party settled Rs.24,917/- on the ground the complainant was suffering from pre-existing disease called COPD.  The contention of the opposite party at the 10^th year of the policy that the mother of the complainant was suffering from pre-existing disease called COPD is absolutely incorrect.  Since as per the terms and conditions of the policy itself the waiting period for any pre-existing disease is 12 months only, but the opposite party at the 10^th year of the policy raised issue that the mother of the complainant was suffering from pre-existing disease called COPD which is totally unbelievable and cannot be accepted.  Therefore the contention taken by the opposite party that the mother of the complainant was suffering from pre-existing disease called COPD is absolutely not correct and also on the basis of the said contention the part payment made by opposite party to an extent of Rs.24,917/- is also in correct.  As per Annexure-3 in patient credit final bill the complainant spent Rs.70,188/- towards medical expenses of his mother and as per the terms and conditions of the Senior Citizens Red Carpet Health Insurance Policy for the sum insured Rs.1,00,000/- the limit of the companies liability is Rs.75,000/- i.e., 75% of the sum insured amount.  Whereas opposite party deducted 50% of the Co-Pay out of total claim and as per Annexure-5 the bill assessment sheet hospital payment submitted by opposite party 75% of the S.I is available.  Therefore we are of the opinion that the deduction   of 50% made by opposite party towards Co-pay and making part payment of Rs.24,917/- to the complainant out of total claim is incorrect.  Therefore we are of the opinion that the complainant is entitle for medical reimbursement from the opposite party at the rate of 75% of the total claim amount which comes Rs.52,641/- (-) Rs.24,917/- which was also paid by opposite party =Rs.27,724/-.  Therefore the complainant is entitle to receive the balance payment of Rs.27,724/- from the opposite party and the opposite party is liable to pay the said amount to complainant.  Hence, we answer point No.1 partly in the affirmative.

16. Point No.2:- For the aforesaid reasons, we proceed to pass the following

:: ORDER ::

The complaint of the complainant is allowed in part.

The opposite party is hereby directed to pay a sum of Rs.27,724/- together with interest @ 10% p.a. to the complainant within 2 months from the date of this order till its realization.

No order as to cost.

Furnish the copy of order to both the parties at free of cost.

(Dictated to the Stenographer transcribed, typed by her, corrected by us and then pronounced in open Forum on this the 4^th August, 2020)