IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Dated this the 27th day of February, 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M. Anto, Member
CC No. 157/2020 (Filed on 08/10/2020)
Complainant : M.C.Suresh,
S/o M.P.Chandrasekharan
Madathinkal House
Maalam P.O, Kottayam
Pin-686 019
Vs
Opposite party : The Branch Manager
M/s Star Health & Allied Insurance Co.Ltd
4th Floor, Carmel Towers
Cotton Hill P.O, Vazhuthacaud
Thiruvananthapuram-695 014
(By Adv.Avaneesh V.N)
O R D E R
Sri.Manulal.V.S, President
The complaint is filed under section 12 of the Consumer Protection Act 1986.
The complaint is filed for compensation on the ground of service deficiency on the part of the opposite parties.
The fact of the case in brief is that the complainant took a Senior Citizen Red Carpet Health Insurance Policy of the opposite party in the name of his mother A.S. Savithri, vide the policy No. P/181113/01/2021/002398. Subsequently, Smt. A.S. Savithri was admitted in J.K. Medicare hospital for vascular headache and urinary tract infection with systemic hypertension on 22-07-2020 and treated there till 24-07-2020 and spent total of Rs.12,057/- towards hospital charges. Thereafter she was taken to S.H. Medical Centre and admitted there on 24-07-2020 and treated there till 28-07-2020 with a DIAGNOSIS OF CVA right hemiparesis and spent total of Rs.22,927/- towards hospital charges. The opposite party allowed an amount of Rs.8,908/- by way of cashless facility. Though the complainant filed a claim for refund of the amount spent for treatment at J.K. Medicare hospital the opposite party allowed only an amount of Rs.4,815/-. The complainant spent a total amount of Rs.34,984/- for the treatment in both hospitals and the opposite party allowed only an amount of Rs.13,723/- and deducted an amount of Rs.21,261/-. The opposite party deducted 50% of the claim amount stating that treatment was for preexisting disease. It is further averred in the complaint that the opposite party had applied 30% co-pay in a claim with regard to previous treatment of the insured for accelerated hypertension in the year 2016 and when the complainant challenged the said deduction the matter was settled between the parties. It is further averred in the complaint that in the year 2016 the opposite party did not consider accelerated hypertension as preexisting disease. According to the complainant the present diagnosis shows that treatment was for vascular headache, urinary tract infection and CVA-right hemiparesis and there was no justification for deduction of 50% of the claim amount as co pay holding that the said disease as pre -existing.
It is alleged in the complaint that the opposite party clubbed the charge of Room rent and nursing expenses together and allowed 1% of the sum assured which is also against the policy condition. Thus in the settlement of claim, the opposite party made arbitrary deductions per se opposed to terms and conditions agreed between the parties. The said act of the opposite party amounts to service deficiency and unfair trade practice, due to which the complainant suffered mental agony. Hence the complaint is filed for a direction to the opposite parties to pay the complainant Rs.21,261/-, being the assured insurance benefit along with Rs.50,000/- as compensation and costs.
The opposite parties entered appearance and filed written version.
As per the version it is admitted that the opposite parties have issued a Senior Citizen Red Carpet Health Insurance Policy in the name of his mother A.S. Savithri, for a period commencing from 28-06-2011 to 27-06-2012 and the same was renewed upto 29-06-2021 for the sum insured of Rs.1,00,000/- vide the policy No. P/181113/01/2021/002398. At the time of issuing the policy, the complainant was supplied with the terms and conditions of the policy. Moreover it is clearly stated in the policy schedule “The insurance Policy is subject to conditions, clauses, warranties, exclusions etc. attached”
As per the terms and conditions of the Senior Citizen Red Carpet Health Insurance Policy, only those pre-existing diseases, which are specifically covered by the proposal form, are covered under the policy. So it is compulsory that the information regarding the health must be provided in the proposal form, for the company to provide coverage with suitable co-payment, ie, 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured. In the proposal form the complainant had specifically declared that his mother was suffering from hypertension.
The complainant had submitted two claims before the opposite party. In CLI/2021/1811113/0182456 the complainant’s mother was admitted at J.K. Medicare hospital on 22-07-2020 for the treatment for accelerated HTN, vascular headache and urinary tract infection and after treatment she was discharged on 24-07-2020. After the treatment complainant submitted a claim form for Rs.11,461/-. The discharge summary, clearly reveals that the mother of the complainant was admitted for general weakness and clinically patient had high BP and the treating doctor noted in the final diagnosis as Accelerated hypertension, vascular headache and urinary tract infection and underwent NTG infusion. As per coverage clause No. J of the policy the policy is subject to co-payment of 50% of each and every claim arising out of all pre-existing diseases and 30% of each and every admissible claim for all other claims will be applicable. On the basis of this clause, the opposite party had settled the claim for an amount of Rs.4,815/- and the same was credited to the account of the complainant on 12-09-2020.
In second claim CLI/2021/1811113/0186875 the opposite party received a pre authorization request for cashless treatment from S H Medical Centre on 24-07-2021 which states that the complainant’s mother was admitted at for the treatment of hypertension and CVA-Right hemiparesis. After receiving the pre-authorization request from, the opposite party had initially authorized an amount of Rs.5,000/- on 25-07-2020.
As per the records of S.H Medical Centre, the complainant’s mother was admitted at hospital with the complaints of right side weakness and her blood pressure value was very high and the ailments was diagnosed as hypertension and CVA-Right hemiparesis. After the treatment, the hospital authorities forwarded the discharge summary with the copy of final bill of Rs.22,997/-.
As per terms and conditions of the policy, the treatment expenses of hypertension and its complication are only payable after apply by 50% co-payment hence the opposite party had approved an amount of Rs.8,908/- on 28-07-2020. In 2016 complainant’s mother treated for GERD was mainly underwent cardiac procedure and USG abdomen. Since the treatment protocol was mainly for cardiac and GERD related, the opposite party had settled he claim with 30% co-payment. As per policy condition the complainant is entitled to room rent 1% of the sum assured as well as nursing expenses under different heads of assessment. The sum assured was Rs.1,00,000 and the room ,boarding and nursing expenses as provided by the hospitals at 1% applicable of the sum assured subject to the maximum of Rs.1,000/- per day and the opposite party has made deduction as per terms and conditions of the policy. There is no deficiency in service on the part of the opposite party.
The complainant filed proof affidavit in lieu of chief examination and documents Ext.A1 to A6 were marked. Padma Prabha who is the Legal Manager of the opposite party filed proof affidavit and marked Exhibits B1 to B11 from the side of the opposite party.
Based on the pleadings and evidence of the rival parties in this case the following issues are framed for consideration.
- Whether there is any service deficiency on the part of the opposite parties?
- If so, what is the relief?
For convenience, all these issues are considered together.
Here the specific case of the complainant is that his insurance claim related to the treatment of his mother, which was filed along with all the documents as required has been partly repudiated by the opposite party without valid grounds.
The opposite parties submit that the insurance policy is subject to conditions, clauses, warranties, exclusions etc. attached. The complainant’s claim was repudiated on the basis of the terms and conditions.
Admittedly the opposite parties have issued a Senior Citizen Red Carpet Health Insurance Policy in the name of his mother A.S. Savithri, for a period commencing from 28-06-2011 to 27-06-2012 and the same was renewed upto 29-06-2021 for the sum insured of Rs.1,00,000/- vide the policy No. P/181113/01/2021/002398. There is no dispute on the fact that in the proposal form the complainant had specifically declared that his mother was suffering from hypertension.
It is proved by Exhibit.A1 that the complainant had spent total of Rs.22,927/- towards hospital charges at S.H. Medical Centre. There is no dispute on the fact that after the treatment complainant submitted a claim form for Rs.11,461/- towards the treatment expenses incurred by him at J.K Medicare hospital. Admittedly the opposite party allowed Rs.8,908/- against the claim amount of Rs.22,297/- and Rs.4,815/- against the claim amount of Rs.11,461.
It is contended by the opposite party that as per terms and conditions of the policy, the treatment expenses relating to pre-existing diseases are only payable after apply 50% co-payment.
We have perused the policy and the terms and conditions. As per Exclusion Clause, the opposite party was not liable to make any payments under the said policy in respect of expenses whatever incurred by insured person in connection with of or in respect of:
(iii) All pre-existing diseases as defined in the policy, existing and suffered by the insured person for which treatment or advice was recommended or received during the immediate preceding 12 months from the date of proposal.
As per clause J of the terms and conditions of the policy 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured.
Bare perusal of the two sub clauses of exclusion (supra) shows that the complainant was still entitled for the claim to the extent of 50% to 70% even if there was pre-existing disease, immediately preceding 12 months from the date of her policy.
Complainant produced Exhibit A6 which was the certified copy of the terms and conditions of the policy which is produced by the opposite party before this Commission in CC No. 224 of 2018. On perusal of Exhibit A6 we can see that as per clause 5 of the exclusion clause 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured. Therefore it cannot be said that the said clause regarding the 50% of co-payment with respect to pre-existing decease is a new condition incorporated by the opposite party without informing the same to the complainant.
It is proved by Exhibit B1 which is the discharge summary issued from J.K. Medicare hospital that the mother of the complainant was admitted for general weakness and clinically patient had high BP and the treating doctor noted in the final diagnosis as Accelerated hypertension ,vascular headache and urinary tract infection and underwent NTG infusion.
Exhibit A2 discharge summary from the S.H. Medical Centre proves that the complainant’s mother was admitted at hospital with the complaints of right side weakness and her blood pressure value was very high and the ailments was diagnosed as hypertension and CVA-Right hemiparesis. Therefore it is evident that the treatment given to the mother of the complainant was for hypertension and its complication which is admittedly a preexisting disease. Hence the complainant is bound to bear 50% of the treatment expenses as co- payment.
As per clause (A) of coverage clause of the policy condition the complainant is entitled to room rent 1% of the sum assured as well as nursing expenses. It is further stated in the terms and conditions of the policy that the expenses relating to the hospitalization will be considered in proportion to the room rent stated in the policy or actual whichever is less. The sum assured was Rs.1,00,000/- and the room, boarding and nursing expenses as provided by the hospitals at 1% applicable of the sum assured subject to the maximum of Rs.1,000/- per day. On perusal of Exhibit A1 we can see that the room rent for 4 days was Rs.4,800/- and the nursing charges for those days was Rs.3,800/-. The complainant is entitled for Rs.4,000/- towards room rent and nursing charges. Hence the case of the complainant is that the opposite party clubbed the charge of room rent and nursing expenses together and allowed 1% of the sum assured which is also against the policy condition is not sustainable.
On a close scrutiny of evidence we are of the opinion that the complainant failed to prove any inadequacy and imperfection in service rendered by the opposite party and to prove deficiency in service on the part of the opposite party. Hence the complaint is dismissed.
Pronounced in the open Commission on this the 27th day of February, 2023.
Sri.Manulal.V.S, President sd/-
Smt.Bindhu.R, Member sd/-
Sri. K.M. Anto, Member sd/-
Appendix
Exhibits marked from the side of complainant
A1- Copy of discharge bill of S.H.Medical Centre, Kottayam dated 28/07/2020.
A2- Copy of cardiology discharge summary of S.H.Medical Centre, Kottayam.
A3- Copy of cashless authorization letter from Star Health and Allied Insurance Co.Ltd. dated 28/07/2020.
A4- Copy of claim form (Part –B) of Star Health and Allied Insurance Company Limited.
A5- Copy of Star Senior Citizens’ Red Carpet Insurance – Proposal
A6- Copy of Star Senior Citizen’s Red Carpet Insurance – Policy.
Exhibits marked from the side of opposite parties
B1- Copy of letter to the complainant dated 30.06.2020.
B2- Customer Information Sheet of Star Health and Allied Insurance Company Limited.
B3- Copy of Star Senior Citizen’s Red Carpet Insurance – Proposal.
B4- Original Discharge Summary of JK Medicare and Diabetes Centre, Vadavathoor, Kottayam.
B5- Copy of discharge bill from J.K Medicare and Diabetes Centre, Vadavathoor, Kottayam dated 24.07.2020.
B6- Copy of claim intimation letter to the complainant dated 16.09.2020.
B7- Copy of request for cashless hospitalization for medical insurance policy.
B8- Copy of cashless authorization letter from Star Health and Allied Insurance Co.Ltd dated 25.07.2020.
B9- Copy of cardiology discharge summary from S.H.Medical Centre, Kottayam dated 28.07.2020.
B10- Copy of discharge bill from S.H.Medical Centre, Kottayam dated 28.07.2020.
B11- Copy of cashless authorization letter from Star Health and Allied Insurance Co.Ltd dated 28.07.2020.
By order
sd/-
Assistant Registrar
