THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM

Dated this 16^th day of August 2024

     Filed on: 27.09.2018

PRESENT

Shri. D.B. Binu                                             President

Shri. V. Ramachandran                                 Member

Smt. Sreevidhia T.N.                                    Member

C.C. No. 402/ 2018

Complainants:

1. Lenin Jithendra Dharamshi, S/o. Jithendra Kumar,Residing at 'Prithruchaya,' Kachappally Lane, Vyttila, Cochin, Ernakulam.

2. Jithendra Kumar, S/o. Padamshi Velgi, Residing at 'Prithruchaya,' Kachappally Lane, Vyttila, Cochin, Ernakulam.

(By Adv.K.Manuraj, Layam Road, Cochin-682 011)

Vs

Opposite Parties:

1. M/s. Star Health and Allied Insurance Company Ltd.,1, New Tank Street, Valluvarkottam, High Road, Nugambakkam, Chennai, PIN – 600 034. Rep. by Senior Manager (claims).

2. Senior Manager  (claims), M/s.Star Health Allie Insurance Company Limited.  1, New Tank Street, Valluvarkottam, High road, Nugambakkam, Chennai, Pin-600 034.

3. Jain International Organization, Panchasheel Maza, A Wing Basement, Near Dharam Palace, Hughed Road, Great Mumbai, Pin -400 007

4. The Manager Claims, M/s.Star Health & Allied Insurance Company Limited, Area Office, 1^st Floor, Jean Rose Building, Near holiday Inn, Chakkaraparambu, Vennala P.O.,  

(ops rep. byBy Adv.R.S.Kalkura, Adv.Harish Gopinath, Adv.Najumal Hussain, Kalkura & Associates)

F I N A L   O R D E R

D.B. Binu, President

1.       A brief statement of facts of this complaint is as stated below:

This complaint was filed under Section 12 of the Consumer Protection Act, 1986, by Lenin Jithendra Dharmashi (1^st complainant) and his father, Jithendra Kumar (2^nd complainant). The complaint was against M/s.Jain International Organisation (3^rd opposite party), a Jain community service provider, and M/s. Star Health and Allied Insurance Company Ltd. (1^st and 2^nd  opposite parties), regarding a group health insurance policy. The policy covered the complainants’ family and was renewed for the period 2018-2019.

In March 2018, the 2^nd complainant sought treatment at Lisie Hospital, Ernakulam, resulting in a total treatment cost of Rs.3,79,663/-. The insurance company reimbursed only Rs.1,43,690/-, citing exclusions and policy terms, including deductions for non-medical expenses and an alleged pre-existing disease. The complainants contested these deductions, stating they were arbitrary and in violation of policy conditions.

The complainants sought a direction from this Commission to reimburse the withheld amount, along with compensation for mental agony and costs incurred during the proceedings.

2. Notice:

Notices were sent to all opposite parties. The 1^st and 2^nd opposite parties filed their versions, while the 3^rd and 4^th opposite parties did not respond.

3. Versions of the Opposite Parties:

The opposite parties contended that the complaint is not maintainable, as no cause of action arose within the jurisdiction of the Commission at Ernakulam. They stated that the 2^nd complainant's condition was a pre-existing disease (PED) and that deductions were made under the policy terms, including a 25% co-payment for PED-related treatments. They also claimed that the hospital charged inflated prices for the IVIG injections, which justified further deductions.

The opposite parties stated that they processed the claim according to the policy’s terms and have already settled the admissible amount. They deny any deficiency in service or unfair trade practices and seek dismissal of the complaint with costs.

4. Evidence:

The complainants did not submit a proof affidavit but filed photocopies of eight documents.

1.       Group Health Insurance Certificate of Insurance (2018-2019) issued by Star Health and Allied Insurance Company Limited, dated 26.04.2018.

2.       Letter issued by Dr. Vidya, Lisie Hospital, Ernakulam, dated 09.04.2018.

3.       Letter issued by Dr. Vidya, Lisie Hospital, Ernakulam, dated 14.04.2018.

4.       Discharge Summary from the Department of Neurology, Lisie Hospital, Ernakulam, dated 14.04.2018.

5.       Detailed Discharge Bill from Lisie Hospital, Ernakulam, dated 14.04.2018.

6.       Authorization for enhancement of the amount issued by Star Health & Allied Insurance Company, dated 16.04.2018.

7.       Letter cum Bill Assessment Sheet for Hospital Payment issued by Star Health & Allied Insurance Company, dated 15.05.2018.

8.       True Copy of the Lawyer Notice, dated 09.06.2018.

Despite being given several opportunities, the complainants failed to provide further evidence or attend the Commission after August 25, 2023, indicating a disinterest in pursuing the case.

5.       Points for Consideration:

i)        Whether the complaint is maintainable or not?

ii)       Whether there is any deficiency in service or unfair trade practice by the opposite parties?

iii)      If so, whether the complainant is entitled to any relief?

iv)      Costs of the proceedings, if any?

6. The issues mentioned above are answered as follows:

i)        Maintainability of the Complaint:

The opposite parties argued that the complaint is not maintainable due to the lack of territorial jurisdiction, as the insurance policy was issued by their Mumbai branch, and the claim was processed at their Chennai office. However, the counsel for the complainants contended that the office of the 4^th  opposite party is within the territorial jurisdiction of this Commission at Chakkaraparambu, Vennala.

According to Section 11(2)(c) of the Consumer Protection Act, 1986, a complaint can be instituted where the opposite party or each of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides or carries on business or has a branch office or personally works for gain. Since the 4th opposite party’s office is located within this Commission's jurisdiction, the complaint is maintainable.

ii) Deficiency in Service and Unfair Trade Practice:

The complainants alleged deficiency in service and unfair trade practices by the opposite parties due to the partial rejection of their insurance claim. However, they failed to provide substantial evidence to support their claims. The complainants' repeated absence and failure to submit a proof affidavit weaken their case significantly.

In the case of SGS India Ltd vs. Dolphin International Ltd (2021 AIR SC 4849), the Supreme Court held that:

"The onus of proof of deficiency in service is on the complainant in complaints under the Consumer Protection Act."

Mere allegations without evidence are insufficient to establish a claim for deficiency in service. As the complainants did not provide sufficient evidence, the Commission cannot hold the opposite parties liable for any alleged deficiency or unfair trade practice.

iii)      Entitlement to Relief:

Given the lack of evidence and the failure of the complainants to substantiate their claims, the Commission finds no basis to award any relief. The complainants have not demonstrated that the opposite parties acted in violation of the policy terms or engaged in any unfair trade practices.

iv)      Costs of Proceedings:

Since the complaint is found to be without merit, the complainants are not entitled to any costs. The opposite parties’ request for costs is also not granted, as the Commission did not find the case to be frivolous or vexatious.

7.       Conclusion and Order:

In light of the above analysis, the Commission concludes that the complainants failed to prove any deficiency in service or negligence on the part of the opposite parties. The complaint lacks merit and is hereby dismissed.

O R D E R:

The complaint is dismissed. No cost.

Pronounced in the Open Commission on this 16^th  day of August, 2024.

Sd/-

D.B. Binu, President

Sd/-

V. Ramachandran, Member

Sd/-

Sreevidhia T.N., Member

                                                                                          Forwarded by Order

                                                                                          Assistant Registrar

APPENDIX

1.       Group Health Insurance Certificate of Insurance (2018-2019) issued by Star Health and Allied Insurance Company Limited, dated 26.04.2018.

2.       Letter issued by Dr. Vidya, Lisie Hospital, Ernakulam, dated 09.04.2018.

3.       Letter issued by Dr. Vidya, Lisie Hospital, Ernakulam, dated 14.04.2018.

4.       Discharge Summary from the Department of Neurology, Lisie Hospital, Ernakulam, dated 14.04.2018.

5.       Detailed Discharge Bill from Lisie Hospital, Ernakulam, dated 14.04.2018.

6.       Authorization for enhancement of the amount issued by Star Health & Allied Insurance Company, dated 16.04.2018.

7.       Letter cum Bill Assessment Sheet for Hospital Payment issued by Star Health & Allied Insurance Company, dated 15.05.2018.

8.       True Copy of the Lawyer Notice, dated 09.06.2018.

Date of Despatch

By Hand:

By  post

uk/