DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 30th day of May, 2024
Present : Sri. Vinay Menon V., President
: Smt. Vidya A., Member
: Sri. Krishnankutty N.K., Member Date of Filing: 27/10/2022
CC/205/2022
S.I.Humayun Kabir,
S/o. Late Ismail Haroon,
ME 35, Mythri Nagar, Thottungal, DPO Road,
Palakkad – 678 004 - Complainant
(By Adv. P. Padmaprakash)
Vs
- M/s. Star Health & Allied Insurance Co. Ltd. – I,
New Tank Road, Valluvarkottam High Road,
Nungampakkam, Chennai – 600 034
Rep. by its Managing Director
- Branch Manager,
M/s. Star Health & Allied Insurance Co. Ltd.,
R.K. Building, Opp. Chitturkavu,
Palakkad Road, Chittur, Palakkad – 678 101 - Opposite parties
(By Adv. M/s. Ratnavally P. & Kiran G Raj A.)
O R D E R
By Sri. Vinay Menon V., President
- Undisputed pleadings highlight the existence of a valid policy whereby the complainant was a beneficiary under a health insurance floated by the O.P.s for Rs.10 lakhs. Subsequent to a hospitalization, the complainant raised a claim for Rs.3,97,561.41. O.P.s allowed only part of the claim to a tune of Rs.1.87 Complainant is aggrieved by the careless scrutiny and reimbursement made by OP. This complaint is filed seeking return of the balance amount of Rs.2,10,561/- along with cost and compensation.
- The opposite party pleaded that they had paid the permissible amount after verification of claim documents. Out of the claim raised, Rs.1,76,000/- and hospital cash benefit of Rs. 5,250/- was found payable under the package charges. The balance amount of Rs.2,21,569/- was part of non-payable items as per the terms and conditions. The complaint is only liable to be dismissed.
- The following issues were framed for consideration:
- Whether the OP had paid full admissible claim amount to the complainant as per the terms and conditions of the policy?
- Whether there is deficiency in service on the part of OPs?
- Whether the complainant is entitled to the reliefs sought for?
- Any other reliefs?
4.(i) Evidence of complainant comprised of proof affidavit and Exhibits A1 to A4. Marking of Ext.A2 is objected to as it is a photocopy. Since this Commission is not bound by Indian Evidence Act and since the OP has no case that Ext.A2 is concocted, objection is overruled.
(ii) O.P. filed proof affidavit and marked Ext. B1 to B4. Marking of B1 to B4 are objected as they are photocopies. Ext.B3 is further objected to as it is a GO unaccompanied by the seal and signature of the authority. Counsel for complainant raised a concern that Ext.B1 to B4 may be concocted. Since the complainant has failed to prove that Ext.B1 to B4 are concocted, they are taken in evidence over-looking the objection of the complainant.
Issue No.1
5. The only question that is to be ascertained is whether the complainant is entitled to the balance amount that was not paid i.e. Rs.2,21,659/-.
In order to prove their case, complainants marked Exts.A1 to A4. Ext.A1 is the policy schedule. Ext.A3 & 4 are communications between the complainant and OPs. Ext.A2 is the final bill of Rs.3,97,569/-, for which the claim is raised.
6. Opposite parties filed Exts. B1 to B4.
Ext.B1 is the policy schedule along with terms and conditions wherein complainant is a beneficiary.
Ext.B2 is the discharge summary.
Ext.B3 is the GO issued by the Govt. of Kerala framing rates for treatment of Covid 19 under ABPMJAY / KASP Health Benefit Package.
Ext.B4 is the bill assessment sheet. Ext.B4 contains four pages. In page 4 of Ext. B4, ‘Remarks’ section shows the reasons for disallowing Rs. 2,21,569. They are:
(1). Stay restricted; (2). Additional Room Rent deducted; and
(3). Medicines, lab consultation and others included as per package rate.
7. OP’s case is that they had granted the admissible to the complainant. Ext.B4 is produced to prove that they had differentiated between the payable and non-payable amounts. It is to be kept in mind that when the opposite party is in a fiduciary relationship with the complainant, they are bound to produce clear statements showing how the repudiation are made and how such deductions are arrived at. A mere statement stating that they had paid the admissible amount will not suffice. O.P., which seeks even the tiniest of details from the complainant and those similarly placed, cannot deviate from their duty to account for the deductions. They are also bound to produce a detailed list of account that can be understood by beneficiaries. The opposite party has not taken any attempt or effort to prove that the deductions made and the amount arrived at is in consonance with the terms and conditions of policy. It is true that the opposite party has filed Ext.B1 terms and conditions and Ext.B4 calculation statement. But these documents will not in any way assist this Commission to come to a conclusion that the deductions made by the opposite parties are in accordance with contractual provisions.
8. Therefore, this Commission has no hesitancy to come to a conclusion that the opposite party has failed is discharging their fiduciary duties to the complainant and to prove that the amounts were paid in accordance with the terms and conditions of Ext.B1 policy.
Issue No. 2
9. We hold that there is deficiency in service on the part of OPs.
Issue No. 3
10. Complainant has sought for the entire balance amount along with Rs.10 lakhs as compensation. Even while holding that there is deficiency in service on the part of opposite party in not providing the reasons for arriving at the non-permitted amount while being in a fiduciary relatiopnship, we are not blind to the fact that the terms and conditions include exclusions and reductions.
11. The complainant is entitled to compensation and cost, but not the entire balance amount. We are also not inclined to permit the entire cost of Rs.10 lakhs claimed as the said amount is excessive.
Issue No. 4
12. In the result, based on the observations and conclusions arrived at supra, we dispose off this CC, holding as below:
1. The O.P.s are directed to provide a detailed statement of account to the complainant showing the reasons for non-permitting of claim.
2. Complainant is entitled to a compensation of Rs. 1,00,000/- payable by the O.Ps.
3. Complainant is entitled to a cost of Rs. 25,000/- payable by the O.Ps.
4. The above directives shall be complied within a period of 45 days from the date of receipt of a copy of this order, failing which, the O.P.s shall pay an amount of Rs.1,000/ per month or part thereof as solatium from the date of this Order till the date of compliance of the directives herein.
Pronounced in open court on this the 30th day of May, 2024.
Sd/-
Vinay Menon V
President
Sd/-
Vidya.A
Member
Sd/-
Krishnankutty N.K.
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 - Original policy schedule
Ext.A2 – Copy of final bill
Ext.A3 - Printout of email communication dated 30/9/2022
Ext.A4 - Printout of email communication dated 30/9/2022
Exhibits marked on the side of the opposite party:
Ext.B1 - Copy of Policy schedule and terms and conditions.
Ext.B2 - Copy of discharge summary dated 10/11/2020
Ext.B3 – Print out of GO (Rt) No. 1246/2020/H&FWD
Ext.B4 – Copy of bill assessment sheet – member payment.
Court Exhibit: Nil
Third party documents: Nil
Witness examined on the side of the complainant: Nil
Witness examined on the side of the opposite party: Nil
Court Witness: Nil
NB : Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
