Punjab

Faridkot

CC/17/390

Rakesh Jain - Complainant(s)

Versus

Star Health Allied Insurance co. - Opp.Party(s)

Rajneesh Garg

13 Mar 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C.C. No. :               390 of 2017

Date of Institution:    8.12.2017

Date of Decision :   13.03.2019

 

Rakesh Jain aged about 51 years s/o Harbans Lal r/o House No. B-II/15, Jain Homeopathic Street, Mohalla Sethian, Near Shiv Mandir, District Faridkot.

...Complainant

Versus

1. Star Health Allied Insurance Company Ltd, Office at 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 through its Authorized Officer/Branch Head.
2. Star Health Allied Insurance Company Ltd, office at First Floor, Himalian House, 23, Kasturba Gandhi Marg, New Delhi-110001.
3. Artemis Health Institute/ Hospital, Sector 51, Guru Gram, through its Authorized Signatory.
4. Artemis Health Institute/ Hospital, Sector 51, having regd office at Plot No.14, Sector 20, Dwarka, New Delhi.
5. Gurmeet Kumar son of Ram Krishan, resident of Mohalla Sethian, District Faridkot.

.....OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt Param Pal Kaur, Member.

 

 

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Present:  Sh  Rajneesh Garg, Ld Counsel for complainant,

               Sh H S Sandhu, Ld Counsel for OP-1 and OP-2,

              OP-3 to OP-5 Exparte.

ORDER

(Ajit Aggarwal, President)

                                          Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to them to make remaining payment of insurance claim of Rs.73,467/-and for further directing OPs to pay Rs.2,00,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses of Rs.15,000/-.

2                                         Briefly stated, the case of the complainant is that on recommendation of OP-5 complainant purchased a Health Insurance Policy from OP-1 and OP-2 and paid Rs.15,284/- to them. OPs issued Policy bearing no. P/700002/01/2017/079113 valid for the period from 10.02.2017 to 9.02.2018 and it covered complainant, his wife Suman Jain, his sons namely Anshul Jain and Nishey Jain and at the time of purchase, none of their family member was suffering from any ailment. It is submitted that complainant got health problem and complained of headache with vomiting. Complainant approached the hospital of OP-3 and OP-4 and got himself checked therefrom and on their advice, he was admitted in their hospital on 21.09.2017 and after some tests , CT Angiography was conducted upon him on 22.09.2017 and all other treatment as per discharge summary was taken by

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complainant and then he was discharged therefrom on 23.09.2017. OPs charged Rs.3,38,525/- from complainant on account of room rent, operation theatre charges, ICU Charges, fees, Investigations, Medicines, Implants and other miscellaneous charges. it is pertinent to mention here that policy in question is a cashless policy and entire amount was to be paid to OP-3 and OP-4 by OP-1 and OP-2, but OP-1 and OP-2 illegally deducted Rs.73,467/-from the bill and complainant had to pay the same from his own pocket. Act of OPs in deducting this amount from the bill amounts to deficiency in service and trade mal practice and it has caused harassment and mental agony to complainant for which he has prayed for directions to OPs to pay Rs.2,00,000/-as compensation alongwith Rs.15,000/- as cost of litigation besides the medical insurance claim. Hence, the present complaint.

3                                              The counsel for complainant was heard with regard to admission of the complaint and vide order dated 12.12.2017, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                                              On receipt of the notice, OP-1 and 2 filed written statement taking preliminary objections that this Forum has no jurisdiction to hear and try the present complaint. It is asserted that there is no deficiency in service on the part of OPs. Complainant purchased the policy in dispute after fully understanding its terms and conditions and no cause of action arises in favour of complainant.

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Complainant has violated the terms and conditions of Policy and he has not come to the Forum with clean hands. Complainant has concealed the material facts from this Forum and thus, he is not entitled for relief sought by him. Complainant has no locus standi to file the present complaint. However, on merits, OP-1 and 2 have denied all the allegations of complainant and reiterated that there is no deficiency on their part. It is asserted that complainant purchased the policy in question for sum of Rs.3 lacs after going through all the terms and conditions of the policy. It is averred that claim was reported in 2^nd year of the policy. It is admitted that complainant submitted his preauthorization request for cashless treatment and same was approved for Rs.2,56,181/-against the total bill of Rs.3,38,525/-and Rs.486/- were deducted on the  ground that as per guidelines of IRDA, Glucometer charges are not payable. Further charges  on account of thermometer, handrub, non sterile gloves, infusion pump, trolley cover, urometer, electrodes, disposables are not payable and amount of Rs.12,219/-was deducted for this. It is averred that as per prevailing market price, the charges towards implant is Rs.65,000/-and Rs.58,032/-were deducted. OP-1 and 2 submitted that complainant never approached them after his treatment for seeking reimbursement of his medical expenses. Complainant never submitted any document like claim form, discharge summary, consultation report and duration of illness, investigation report and medical bill alongwith prescriptions to them for obtaining claim on account of  expenditure made by him for his treatment. As per terms and conditions of the

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policy, for obtaining insurance claim all these documents are necessary to be submitted to them and therefore, complaint filed by complainant is premature and is not maintainable. All the other allegations are denied being wrong and incorrect and prayer for dismissal of complaint with costs is made.

5                                                        OP-3 and OP-4 filed reply taking preliminary objections that complaint in the present form is not maintainable and is liable to be dismissed and it is a false, frivolous and wrong complaint, filed with malafide intention and is not sustainable in the eyes of law. It is averred that no cause of action arises against them and this Forum has no jurisdiction to hear and try the present complaint. It is averred that no relief is sought against them by complainant and complaint is bad for joinder of unnecessary parties. It is further averred that contract of insurance is between complainant and OP-1 and OP-2 and they have no role in making payment of treatment expenses as sought by him. It is asserted the only part to be played by OP-3 and Op-4 is to provide the standard treatment of care to the patient, which they have given with full care. Complainant was admitted in the hospital of OP-3 on 21.09.2017 with complaints of headache and vomiting since seven days and he was given best treatment and was relieved from their hospital on 23.09.2017 in a stable condition. At the time of admission, complainant gave detail of his mediclaim policy issued by OP-1 and OP-2 and his case was sent to Op-1 for Rs.3,38,525/-and they passed the same for Rs.2,65,058/-and remaining amount of Rs.73,467/-was paid by

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complainant. However, on merits OP-3 and OP-4 have denied all the allegations of complainant being wrong and incorrect and asserted that they have given best treatment to complainant and it is reiterated that there is no deficiency in service on the part of answering OPs and prayed for dismissal of complaint with costs.

6                                      Notice containing copy of complaint and other relevant documents was duly served to OP-5, but despite having sufficient knowledge about the complaint against them, nobody appeared in the Forum on date fixed on behalf of OP-5 either in person or through counsel. It was presumed that OP-5 was not interested in contesting the complaint and therefore, vide order dated 7.02.2018, complaint against OP-5 was dismissed.

7                                               Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to C-10 and then, closed his evidence.

8                                                 In order to rebut the evidence of the complainant, counsel for OP-1 and OP-2 tendered in evidence affidavit of N Gopalan Ex OP-1, 2/1 and documents Ex Op-1, 2/2 to Ex OP-1, 2/3 and closed the same on behalf of OP-1 and OP-2.

9                                                After filing the written statement, OP-3 and OP-4 did not make appearance in the Forum and therefore, vide

 

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order dated 30.05.2018, they were proceeded against exparte and therefore, there is no evidence on behalf of OP-3 and 4.

10                                                 We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

11                                      Ld Counsel for complainant vehementally argued that at the instance of OP-5 agent of OP-1 and OP-2, complainant purchased a Health Insurance Policy for a sum of Rs. 3 lacs and paid Rs.15,284/- as premium. Policy was valid from 10.02.2017 to 9.02.2018 and it covered complainant, his wife and his two sons and at the time of purchase, none of their family member was suffering from any ailment. Complainant suffered from problem of headache with vomiting and after getting himself checked up from the hospital of OP-3 and OP-4, he was admitted in their hospital on 21.09.2017 and after some tests, CT Angiography was conducted upon him on 22.09.2017 alongwith other treatment and then he was discharged therefrom on 23.09.2017. OPs charged Rs.3,38,525/- from complainant on account of room rent, operation theatre charges, ICU Charges, fees, Investigations, Medicines etc and as per policy in question, entire amount was to be paid to OP-3 and OP-4 by OP-1 and OP-2, but OP-1 and OP-2 illegally deducted Rs.73,467/-from the bill and complainant had to pay the same from his own pocket. Act of deducting this amount from the bill amounts to deficiency in service  on their part and it has caused harassment to him.

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He has prayed for accepting the present complaint and stressed on documents adduced by him.

12                                  To controvert the allegations of complainant, ld counsel for OP-1 and OP-2 argued that there is no deficiency in service on their part. Complainant purchased the policy in question for sum of Rs.3 lacs after going through all the terms and conditions of the policy. Claim was reported in 2^nd year of the policy and he submitted his preauthorization request for cashless treatment, which was approved for Rs.2,56,181/- against the total bill of Rs.3,38,525/-. It is  brought before the Forum that and Rs.486/- were deducted on the ground that as per guidelines of IRDA, Glucometer charges are not payable and charges for thermometer, handrub, non sterile gloves, infusion pump, trolley cover, urometer, electrodes, disposables are also not payable and thus, Rs.12,219/-were deducted for this. As per prevailing market price, the charges towards implant is Rs.65,000/-and Rs.58,032/-were deducted. Ld counsel for OP-1 and 2 argued that complainant neither approached them after his treatment for reimbursement of his claim nor he submitted any document like claim form, discharge summary, consultation report and duration of illness, investigation report and medical bill alongwith prescriptions to them for obtaining claim on account of  expenditure made by him for his treatment. As per terms and conditions of the policy, for obtaining insurance claim all these documents are necessary to be submitted to them, but complainant did not submit any requisite document to them and therefore, complaint filed by complainant is

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premature and is not maintainable. Prayer for dismissal of complaint is made.

13                                   As there is no rebuttal from OP-3 and OP-4, therefore, pleadings taken by them in written statement are considered as arguments advanced by them. As per OP-3 and OP-4 contract of insurance is between insured and insurer i.e complainant and OP-1 and OP-2 Insurance Company and they have no role in making payment of treatment expenses. Only duty of OP-3 and OP-4 was to provide the standard treatment of care to the patient, which they have done with full care. He was admitted in their hospital on 21.09.2017 with complaints of headache and vomiting since seven days and he was given best treatment and was discharged from their hospital on 23.09.2017 in a stable condition. At the time of admission, complainant gave detail of his mediclaim policy, his case was sent to OP-1 for Rs.3,38,525/-but they passed the same for Rs.2,65,058/-and remaining amount of Rs.73,467/- was paid by complainant. There is no deficiency in service on their part and even complainant has not sought any relief from them. Prayer for dismissal of complaint is made.

 14                              From the careful perusal of the record and after going through the evidence and documents available, it is observed that case of the complainant is that he was insured under the policy in question and as per policy, he was entitled for cashless treatment. He

 

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got conducted his treatment from the hospital of OP-3 and OP-4. Hospital authorities charged Rs.3,38,525/-but OP-1 and OP-2 cleared the bill for Rs.2,65,058/-to hospital authorities and illegally deducted Rs.73,467/-from total bill and complainant had to pay this amount from his own pocket. Grievance of complainant is that as per terms and conditions of the policy, complainant was entitled for cashless treatment and all expenses on account of treatment of complainant were to be borne by the Insurance Company/OP-1 and OP-2, but despite repeated requests, they have not made reimbursement of this amount, which amounts to deficiency in service. He has prayed for accepting the complaint. In reply, OP-1and 2 have stressed mainly on the point that claim of complainant was reported in second year of the policy and he submitted his request for preauthorization, which was duly approved and his bill was cleared after deduction of some charges as per terms and conditions of the policy and as per guidelines of the IRDA. As per them, they have already paid the reasonable amount admissible as per rules & as per terms and conditions of policy and now, nothing is due towards them. Complainant is not entitled for further relief of claim amount as sought by him. Moreover, they have stressed on the point that after treatment, complainant did not approach them for reimbursement of his claim. Even complainant has not submitted any requisite documents required for the purpose of obtaining reimbursement. It is reiterated that there is no deficiency in service on their part and prayed for dismissal of complaint with costs.

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15                                                          There is no dispute regarding insurance of complainant with OPs. Ops have themselves admitted that he was insured with them as per Family Medicare Policy. OP-1 and 2 argued that as per policy terms and conditions and reasonable rate for the treatment under policy in question, his request for preauthorization for his treatment expenses was approved and paid to hospital authorities and now, complainant is not entitled for any other amount or reimbursement than this and this amount has already been paid, but no plausible reason is put forward by them to justify that why they have not made payment of entire claim amount. They have not placed on record any documentary evidence or statement showing that why they deducted this amount on their own and how they assessed the reasonable rate of treatment. Admittedly, the complainant spent Rs.73,467/- from his own pocket though he was entitled for cashless treatment. Insurance Companies cannot fix their own rates at their own will than the actual expenses borne by the persons.

16                                                            Ld Counsel for complainant argued that the OPs cannot deduct the amount in dispute out of claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are

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required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The conditions, which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any Policy. The Insurance Companies in such cases rely upon the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy. He further put reliance upon citation 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others, wherein our Hon’ble Punjab and Haryana High Court held that Contract act, 1872-Insurance Act, 1938-contract among unequal – Validity – Mediclaim Policy - Exclusion Clause – Pre Existing Disease - Exclusion Clause is standard form of contracts – when bargaining power of the party is unequal and consumer has no real freedom to contract-Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power.

17                   From the above discussion and case law produced by the complainant, we are of considered opinion that OP-1 and OP-2 have

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wrongly and illegally deducted this amount, on false grounds of terms and conditions of policy, which was covered under the Mediclaim insurance policy. From the documents produced by the complainant it is proved that he spent Rs.73,467/-for his treatment from his own pocket which is not paid by OP-1 and OP-2, which is also admitted by all the OPs. The OP-1 and 2 have failed to prove that how they deducted this genuine amount. Hence, present complaint is hereby accepted and OP-1 and OP-2 are directed to pay Rs.73,467/-to complainant alongwith interest at the rate of 9% from the date of filing the present complaint till final realization, which was wrongly deducted by them from the bill amount of Rs.3,38,525/-. OP-1 and OP-2 are further directed to pay Rs.5,000/-to complainant as consolidated compensation for harassment and mental agony suffered by him and as litigation expenses. Compliance of this order be made within prescribed period of 30 days of receipt of the copy of this order, failing which complainant shall be entitled for interest at the rate of 9 % per anum per anum on the award amount from the date of order till final realization. OP-3 to OP-5 have no role in making reimbursement of this amount and therefore, complaint against them stands hereby dismissed. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 13.03.2019

 

(Param Pal Kaur)              (Ajit Aggarwal)

                                       Member                          President