Punjab

Faridkot

CC/21/86

Anoopinder Singh Sekhon - Complainant(s)

Versus

Star Health Allied Insurance - Opp.Party(s)

Yash Pal Bansal

30 Jan 2023

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FARIDKOT

 

                        C. C. No. :                86 of 2021

Date of Institution:    19.05.2021

Date of Decision :      30.01.2023

 

Anoopinder Singh Sekhon son of Sh Harphool Singh resident of Street No.-2, Mohalla Mahikhana, Faridkot District Faridkot.

                                                                                   .........Complainant

Versus

Star Health and Allied Insurance Company Limited No.15 Sri Balaji Complex, 1^st Floor, Whites Lane, Royalpettah, Chennai 600014.                                                                         

.............OP

Complaint under Section 35 of the

Consumer Protection Act, 2019.

 

Quorum: Sh. Kanwar Sandeep Singh, President,

               Smt  Param Pal Kaur, Member,

     Sh Vishav Kant Garg, Member.

 

Present: Sh Yash Pal Bansal, Ld Counsel for Complainant,

              Sh Atul Gupta, Ld Counsel for OP.

 

* * * * * *

ORDER

(Kanwar Sandeep Singh, President)

                                   Complainant Anoopinder Singh (hereinafter referred to as complainant) has filed this complaint under section 35 of the Consumer Protection Act 2019 (hereinafter referred as ‘Act’

 

 

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before this Commission against Star Health and Allied Insurance Company Limited (hereinafter referred as Opposite party).

2                                          Briefly stated, the case of the complainant is that complainant purchased a Family Medicare Policy bearing no. P/211222/01/2021/002386 valid from 24.07.2020 to 23.07.2021 from OP for sum assured of Rs.5 lacs and during the subsistence of said policy on 20.02.2021, complainant was admitted in Fortis Hospital, Ludhiana and he was discharged therefrom on 22.02.2021. He paid Rs.3,24,858/-to hospital authorities for his treatment.

3                               It is alleged that Opposite Party reimbursed the amount of Rs.2,85,530/-and withheld the remaining amount without assigning any reason. Deduction of remaining amount from the entire claim amount by Opposite Party is unlawful and illegal.

4                               It is further alleged that Opposite party deprived him of remaining amount of Rs.39,328/-for long time and therefore, he is entitled to claim interest over this amount.

 

 

 

 

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5                                       It is further alleged that complainant made several requests to Opposite Party to clear the entire claim, but they did not do anything needful.

6                                              It is further alleged that action of Opposite party in not making payment of entire claim amount and the act of passing part payment and withholding the remaining amount, amounts to deficiency in service. Complainant has alleged that he  had suffered huge financial loss as well as harassment and mental agony due to this act of Opposite Party, which amounts to deficiency in service and trade mal practice.

7                                          On this backdrop of facts, the complainant has prayed for directions to Opposite Party to make payment of remaining amount of Rs.39,328/-(wrongly calculated as Rs.42,328 by complainant) to complainant and to pay compensation to the tune of Rs.50,000/-  for harassment and mental agony suffered by him alongwith litigation expenses of Rs.11,000/-. Hence, the present complaint.

 

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8                                               Learned counsel for complainant was heard with regard to admission of the complaint and vide order dated 08.06.2021, complaint was admitted and notice was ordered to be issued to the Opposite Party.

9                                               On receipt of the notice, OP filed written statement taking preliminary objections that complaint filed by complainant is just an abuse of process of law. Policy is a legal contract between complainant and insured and it is governed by as per terms and conditions and as per terms and conditions of the policy in question, amount of Rs.2,85,530/-have already been paid to complainant. Complainant submitted claim for reimbursement of Rs.3,24,858/- towards his treatment and out of this, Rs.2,85,530/-were settled to the insured and reason for deducting the remaining amounts is that as per terms and conditions of the policy, Resident Medical Officer or duty doctor charges are not payable because it is expected to be a part of room rent and nursing fees and thus, Rs.400/-were deducted on this ground  and Rs.320/-were deducted on account of Random Blood Sugar which are excluded expenses. Further averred that complainant has not  provided invoice for implant and

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therefore, Rs.12,907/- i.e 20% of claim amount are deducted. Rs.24,800/- are deducted on the ground that complainant has not supplied break up details for package charges and Rs.900/-are deducted for not providing detail for other procedure. Moreover, hospital discount of Rs.4000/-has not been paid by complainant and therefore, he is not  entitled for this amount of Rs.4000/-. As per opposite party, it has rightly deducted Rs.39,327/-from the claim amount of Rs.3,28,857/-and Rs. 2,85,530/-have been rightly paid to him and thus, there is no deficiency in service on their part. On merits, ld counsel for OP admitted that complainant was insured with them under policy in question, but has denied all the other allegations being wrong  and incorrect. Opposite party has reiterated the same pleadings as taken in main reply and  asserted that there is no deficiency in service on their part. Prayer for dismissal of complaint with costs is made.

10                                  Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-3 and then, closed their evidence.

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11                                 In order to rebut the evidence of the complainant, Counsel for OP tendered in evidence affidavit of Sumit

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Kumar Sharma Ex OP-1 and document Ex OP-2 and then, closed the evidence on behalf of OP.

12                                  We have heard the ld counsel for complainant as well as OP and have carefully gone through evidence and documents placed on record by respective parties.

13                                  From the careful perusal of the record and after going through the evidence and documents, it is observed that  case of the complainant is that complainant was insured with opposite party under the policy in question and he got conducted his treatment from Fortis Hospital, Ludhiana during his stay in hospital for the period from 20.02.2021 to 22.02.2021 and complainant spent Rs.3,24,858/-on his treatment. Complainant lodged claim with Ops, but Ops made part payment of Rs.2,85,530/-only and withheld the reimbursement of remaining amount. Grievance of complainant is that despite repeated requests, OP has refused to make payment of remaining claim amount to complainant which amounts to deficiency

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in service. He has prayed for accepting the complaint. In reply, OP have stressed mainly on the point that they have already paid the reasonable amount admissible as per rules and as per terms and conditions of policy and nothing is due towards them. Complainant is not entitled for further relief of claim amount as sought by him. Further, they have stressed on the point that complainant opted for expensive procedure which is beyond the approved rates. Complainant submitted claim for reimbursement of Rs.3,24,858/- towards his treatment and out of this, Rs.2,85,530/-have been paid and as per terms and conditions of the policy, Resident Medical Officer or duty doctor charges are not payable and Random Blood Sugar charges are excluded expenses. Complainant did not furnish invoice for implant and thus, Rs.12,907/- i.e 20% of claim amount are deducted and Rs.24,800/- are deducted for not supplying break up details for package charges and Rs.900/-are deducted for not providing detail for other procedure. Opposite Party has rightly deducted Rs.39,327/-from the claim amount of Rs.3,28,857/-and Rs. 2,85,530/-have been paid to him. Reasonable reimbursement as per terms and conditions of policy has already been made to complainant.

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It is reiterated that there is no deficiency in service on the part of Opposite Party.

14                                    From the careful perusal of evidence and documents placed on record and pleadings made by respective parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. OP have themselves admitted that complainant was insured with them as per Family Medicare Policy. The case of the complainant is that he purchased a family medicare policy from Opposite Party and during the subsistence of said policy, he underwent treatment at Fortis Hospital, Ludhiana, where he spent Rs.3,24,858/-to hospital authorities, but OP paid only Rs.2,85,530/-and retained the balance amount of Rs.39,328/-for no reason. The version of the OP is that as per policy, the complainant is eligible to get benefit of hospitalization on customary and reasonable rates. Opposite party is liable to pay claim for standard and effective treatment which is needed and not for excluded expenses. He is not entitled to claim expenses for the same. He is entitled only for expenses as per terms and conditions of insurance policy in question which are already paid to the complainant as per customary and

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reasonable rates and now, nothing is due towards the OP. As per Bill Assessment Sheet-Member Payment, OP has averred that RMO Charges and RBS charges are not payable.

15                                      This Commission is of the view that no justifiable reason is put forward by Opposite Party to clear the point that why they have deducted this amount. Opposite Party unnecessarily deducted 20% of claim amount and 10% on account of package for not furnishing break up detail. It is observed that Opposite Party is interested only in earning money but at the time of making payment, Opposite Party imposes false terms and conditions that have never been supplied to complainant. Opposite Party did not justify that why this huge deduction is made and how did they calculate to deduct these charges that have been paid by complainant to hospital authorities. Opposite Party has nowhere explained that how they assessed these rates as reasonable and customary. Opposite Party has not produced any document to prove that they have assessed these rates as per prevalent market rate. On the other hand, complainant has furnished sufficient and cogent evidence and all documents placed on record by him are authentic and are beyond any

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doubt. We further observed that complainant has not claimed an amount of Rs.4000/-i.e discount given by hospital.

16                       From the above discussion, we come to the conclusion that there has been deficiency in service on the part of Opposite Party in not clearing the entire claim of complainant. Hence, complaint in hand is hereby partly allowed with direction to Opposite Party to make payment of remaining claim amount of Rs.39,328/- that OP intentionally withheld without assigning any justifiable reason. 6% interest over Rs.39,328/-be also paid by OP to complainant from the date of filing the present complaint till final realization. Opposite party is further directed to pay Rs.5,000/-to complainant as consolidated compensation for harassment and mental agony suffered by him as well as for litigation expenses incurred by him.

17                           The compliance of this order be made within prescribed period of 45 days of receipt of the copy of this order, failing which complainant shall be entitled to proceed as per Consumer Protection Act.

 

 

 

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18                               The complaint could not be decided within the statutory period due to heavy pendency of cases.

19                                   Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Commission

Dated : 30.01.2023

     (Vishav Kant Garg)  (Param Pal Kaur)    (Kanwar Sandeep Singh)

      Member                   Member                 President