COMPLAINT FILED ON:14/09/2021
DISPOSED ON:01/10/2021
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, CHITRADURGA.
CC.NO:80/2021
DATED: 1st October 2021
PRESENT: - Smt. H.N. MEENA. B.A., LL.B., PRESIDENT
Sri. G. SREEPATHI, B.Com., LL.B., MEMBER
Smt. B.H. YASHODA. B.A., LL.B., MEMBER
……COMPLAINANT/S | Sri. G.R. Sunil S/o G.N. Rudra Reddy, Aged about 51 years, R/o 1234, Hanumakrupa Gagana, 5th Cross, JCR Extension, Chitradurga-577 501. (Rep., by Sri.R.K. Govindaraju, Advocate) |
V/S |
….OPPOSITE PARTY/S | 1. Star Health and Allied Insurance Company Limited, Regd., And Corporate Office.1, New Tank Street, Valluvarkottam High Road, Nungambakkam, Channai-600034, Represented by its Manager. 2. Star Health and Allied Insurance Company Limited, Kadli Kotrappa Complex, No. 2670,3rd Floor, MCC ‘B’ Block, Opp., Bapuji Dental College, JJMC Main Road, Davanagere-577004, Represented by its Manager. |
By Smt. B.H. Yashoda, Lady Member.
-: Orders on Maintainability of complaint:-
The complainant has filed this complaint against Ops and prays before this Commission to pass Judgment and award or grand of compensation against Ops for a sum of Rs. 2,78,135/- with interest of the rate of 12% p.a and mental agony Rs. 40,000/- and Opponents to pay Rs. 20,000/- towards the cost of proceedings and incidental charges of the case.
The brief facts of the complaint:-
The complainant taken family health Optima Insurance plan policy from the Op No.2 policy no. P/141118/01/2020/0006129. Op No.1 i.e. head office located at Chennai.
Further, the complainant admitted to BIG Hospital, Bengalore suffered by Covid-19 taken treatment from 09/09/2020 to 18/09/2020. The same is intimated by the complainant. The same is intimated by the complainant to Op Health Insurance Company. The Hospital Authorities charged Rs.4,92,383/- but the Op Health Insurance Company settled only Rs. 2,11,465/- after deduction the Hospital discount of Rs. 2,783/-. The complainant is not satisfied by the Op Company claim settlement. The complainant wrote a letter on 27/11/2020 but the Ops are not given any reply against the complaint sent on email on 28/11/2020 requesting to settle the balance amount.
The Ops simply saying as per the terms and conditions of the Policy some medicines are not covered like that, but there is a clear guidelines from Govt., of India that all Health Insurance Policies should cover under Covid-19 and also as per the guidelines of IRB. In-spite of it the Op Health Insurance Company not settled the balance amount of Rs. 2,78,135/- by this act of Op Insurance Company, the complainant suffered mentally, financially and the Ops have done unfair trade practice towards the complainant hence the complainant has filed this complaint before this Hon’ble Commission.
On perusal of the complaint and documents submitted by the complainant Discharge summary of the Big Hospital, Bangalore and Health Insurance policy issued by the Ops to the complainant. During the course of Insurance policy, the complainant was suffering from Covid-19 Pandmic disease and effected by that disease and the complainant was admitted to Hospital for taking treatment of Covid-19 and incurred heavy Medical Expenses to a tune of 4,94,383. In this regard, immediately, the complainant has informed to the Ops about the disease affected by the complainant Policy Holder. That the Ops have paid Rs. 2,11,465/- out of the complainant’s claim amount of Rs. 4,94,383/-. As such, the complainant claims for the balance Claim amount of Rs. 2,78,135/- from the Ops. But, it is noticed that the complainant have not produced the details of the Medical Expenses pertains to claim amount of Rs. 4,94,383/- as such, the Ops paid the settled amount of Rs. 2,11,465/-. Hence, the complaint filed by the complainant is not maintainable for claiming of Balance amount of Rs. 2,78,135/-. Once the complainant has accepted the amount offered by the Ops, it is deemed to be case closed.
Hence as discussed above the complaint is not maintainable before this Commission and accordingly we proceed to pass the following:
O R D E R
The complaint filed by the complainant is not maintainable before this Commission for adjudication on maintainability and hence the same is rejected.
Lady Member Member President
