By Sri. A.S. Subhagan, Member:
This is a complaint preferred under Section 35 of the Consumer Protection Act 2019.
2. Facts of the case in brief:- The Complainant is the holder of Health Insurance Policy No.P/181314/01/2022/009455 with the Opposite Party for the period from 03.03.2022 to one year, having insurance coverage amounting to Rs.2,00,000/-. Things being so, the Complainant underwent a surgery for treatment of his eye in Shri Saradha Eye and ENT Clinic, Sulthan Bathery for which he has spent Rs.32,000/- as expenses for treatment. The Complainant had submitted claim application to the Opposite Party, through the hospital, together with cash bill. But the Opposite Party paid only Rs.15,000/- instead of Rs.32,000/-. This is deficiency in service/unfair trade practice from the part of the Opposite Party. Hence, this complaint with prayers.
- To direct the Opposite Party to pay the full amount of the claim of
Rs.32,000/- with interest at the rate of 12%.
- To direct the Opposite Party to pay Rs.25,000/- towards mental agony.
- To direct the Opposite Party to pay Rs.25,000/- towards cost of this complaint and
- To direct the Opposite Party to pay Rs.10,000/- towards compensation.
3. Opposite Party, on getting summons, appeared before the Commission and
filed version, the contents of which in brief are as follows:- The policy of the Complainant is admitted. Also admitted the treatment and surgery and the submission of claim application of Rs.32,000/- for reimbursement of medical expenses. It is contented by the Opposite Party that as per the terms and conditions of the policy, the expenses payable during the entire policy period for the treatment of cataract is limited to Rs.15,000/- for a sum insured of Rs.2,00,000/-. Rs.15,000/- which is the payable amount of claim under the policy has been paid to the Complainant. So there has been no deficiency in service/unfair trade practice from the part of the Opposite Party and hence the Complaint is to be dismissed with compensatory cost to the Opposite Party.
4. Proof affidavit was filed by the Complainant, Exts.A1 to A3 marked and he was examined as PW1. Opposite Party adduced no oral evidence but Ext.B1 was marked from their side. The complaint was finally heard on 29.05.2023.
5. Considering all the issues, documents marked, evidence adduced and the arguments of the counsels for the Complainant and the Opposite Party, we raised the following points for consideration.
- Whether there has been deficiency in service/unfair trade practice from the part of the Opposite Party?
- Whether the Complainant is eligible for getting the full amount of the insurance claim?
- Other relief and cost?
6. Point No.1:- We perused the complaint, version, affidavit of the
Complainant, his oral evidence, Exhibits marked from both the sides and the arguments of the counsels in detail and seen that following are the admitted facts.
- The policy of the Complainant with the Opposite Party.
- The surgery and treatment of the Complainant in the hospital.
- The submission of claim application for Rs.32,000/- to the Opposite Party and
- The payment of claim of Rs.15,000/- to the Complainant.
7. The allegation of the Complainant is that the total amount of expenses
for treatment and surgery of his eye came to Rs.32,000/- for which he had submitted claim application to the Opposite Party for reimbursement, but the Opposite Party paid only Rs.15,000/-. But the contention of the Opposite Party is that the treatment and surgery of the Complainant was for “Cataract” for which the maximum limit of amount payable as claim, as per the terms and conditions of the policy, is only Rs.15,000/- which has been paid to the Complainant. In oral examination, the Complainant (PW1) has deposed that “Customer information sheet  Contract treatment s\ Ipd¨v hy-à-ambn ]d-bp-¶p-s¶v ]d-ªm icn-bÔ. “Xnanc NnIn-Õbv¡v 15,000/þ cq] am{Xta maximum e`n¡q F¶v ]d-ªm icn-bÔ. But on scrutiny of Ext.A2, in the description column for details of ailment diagnosed (primary) it is stated as “Cataract”. So, the above deposition in oral evidence by the Complainant is seen not true. Moreover, on page number ‘5’ of Ext.B1 which is the customer information sheet, it is seen stated that the expenses during the entire policy period for treatment of “Cataract” under the policy, with a sum assured of Rs.2,00,000/-, is Rs.15,000/-. This eligible amount of claim has been seen given by the Opposite Party to the Complainant which has been admitted by the Complainant. Hence, it is proved that there has been no deficiency in service/unfair trade practice from the part of the Opposite Party. So, point No.1 is proved against the Complainant.
8. Point No.2:- As the eligible amount of claim as per the terms and conditions
of the policy has already been disbursed to the Complainant, he is not eligible for getting any additional amount as claim. So, point No.2 is proved against the Complainant.
9. Point No.3:- As point No.1 and 2 are against the Complainant, he has no
right to get compensation or cost from the Opposite Party.
In the result, the complaint is dismissed but without costs.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 17th day of June 2023.
Date of filing:23.12.2022.
PRESIDENT: Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:
PW1. Gangadharan Nair. Complainant.
Witness for the Opposite Party:
Nil.
Exhibits for the Complainant:
A1. Copy of Insurance Policy details.
A2. Copy of Claim Form- Part B.
A3. Copy of Bill of Supply.
Exhibit for the Opposite Party:
B1. Copy of Customer Information Sheet- Senior Citizens Red Carpet Health
Insurance Policy.
PRESIDENT: Sd/-
MEMBER : Sd/-
