D.O.F:28/07/2020
D.O.O:29/11/2024
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION KASARAGOD
CC.85/2020
Dated this, the 29th day of November 2024
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SMT. BEENA. K.G : MEMBER
1. Abdul Khader.K.M,
2. Mariyambi Abdul Khader,
No.1 and 2 are residing at Little Hut,
Koppal, Pallam Road, Kasaragod. : Complainant
(Adv: M. Balagopalan)
And
Star Health and allied
Insurance Co. Ltd,
No.15, Sri Balaji Complex,
1st Floor, Writer Lane,
Royapettah, Chennai. : Opposite Party
(Adv: Vinod Kumar.K)
ORDER
SRI. KRISHNAN.K : PRESIDENT
The case of the complainant is that they obtained a Health Insurance policy for the period 27/07/2019 to 26/07/2020 from Opposite Party. The second complainant became ill due to eye decease, headache and nausea. She was consulted with Dr. Jayaram Shetty Mangalore, doctor advised admission on 20/11/2019 for Bilateral Primary Open angle Glaucoma, hospital charged Rs. 14685/- and Rs. 3910/- for tests made outside. The complainant put up their claim for the amount. But Opposite party repudiated the claim on the ground that hospitalization was not absolute necessity for the illness. The act of Opposite party caused monitory loss mental pain and sufferings. For which complainant is claiming policy benefits and compensation and cost of litigation.
The Opposite party filed written version. The opposite party denies the liability. The opposite party admitted the insurance policy during the period. The insurance policy is generated by terms and conditions there in. The Opposite party admitted that 2nd complainant was hospitalized for the treatment as shown in the complaint for the treatment of Bilatral primary open angle glaucoma on 20/11/2019 and discharged on 21/11/2019.
The medical records reveals that she was admitted only for claiming Insurance benefits. Outpatient treatment alone is required in the case. Repudiation is as per policy conditions. If at all complainant is entitled to claim of Rs. 17486/- and the complainant is filed for the harassing the opposite party’s and prayed to dismiss the complaint.
The complainant filed documents Ext A1 to A10 marked Ext A1 and A2 prescription and Ext A3 to A10 bills. The documents summoned by order in IA marked as Ext X1. The Opposite party was cross examined as Dw1 Ext B1 Marked.
Considering the rival contentions following points arised for consideration in this case.
- Whether repudiation of the insurance claim is justified on the ground that admission in hospital is not required for the treatment?
- Whether there is any deficiency in service of opposite party? And whether complainant is entitled for compensation? If so for what reliefs?
All the points are taken together for consideration
The complainants grievance is that opposite party denied the insurance benefits. The opposite party says that for the particular treatment hospitalization is not required, complainant ask admission for getting insurance benefits.
The fact remains that complainant obtained Insurance policy for the period. The Opposite party fairly admit issuance of the policy but deny the liability on the ground that illness of the complainant, nature of treatment, admission in hospital is absolutely not necessary.
In para 15 of the written version, opposite Party clearly stated that even though claim is not payable as per terms and conditions of the policy if liability is found, liability may be limited to payment of Rs. 17,486/- only.
Here is claim for health insurance policy benefits covered by the policy. The physician advised admission in the hospital and under treatment as an inpatient opposite party has no case that claim of insurance is not genuine but objects as the grand that and admission and an impatient is not absolutely necessary.
Whether admission as an impatient in the hospital is necessary or not is to be decided by physician and not by insurance company. The opposite party even brought Dw1 Dr.Kishore Krishna to say for eye decease admission not required. He says he referred treatment by physician by testing. So by physicians advice patient is admitted in the hospital and incurred the expenses.
The opposite party admits the liability to the extend of Rs. 17,486/-. But complainant is filed in 2020 long four year over still company did not pay the amount for no valid reason.
The Commission finds that the claim of complainant that she was treated as inpatient during the period is genuine and the period of treatment is covered by valid insurance policy and repudiation on the ground that admission of patient in the hospital for treatment of the illness is not justifiable. Thus commissions finds that opposite party is liable to pay the treatment expense.
The amount is due and payable and due is from the year 2019 complaint is filed on 2020 till date opposite party did not pay the Insurance claim even though opposite party stated in the version that they are willing to pay Rs. 17486/-. There is thus deficiency in service from opposite party side. For which complainant is entitled for compensation. In the circumstances of the claim, benefit claimed are below twenty thousand only, but great mental agony is caused to the policy holder is not paying the mount due, the Commission is of the opinion that, sum of Rs. 10,000/- (Rupees Ten thousand only) is found reasonable compensation. The complainant is also entitled for cost of the litigation.
In the result complaint is allowed in part opposite party is directed to pay Rs. 17,486/-(Rupees Seventeen Thousand and four hundred and eighty six only) as Insurance policy benefit with 8% interest per annum from the date of filing complaint till date of payment and Rs. 10,000/-(Rupees Ten thousand only) as compensation for deficiency in service Rs. 5,000/- (Rupees Five thousand only) cost of litigation to the complainant within 30 days for the receipt of the order.
Sd/- Sd/-
MEMBER PRESIDENT
Exhibits
A1 &A2- Prescriptions
A3- Discharge bill
A4- Tax invoice Dt: 19/10/2019
A5- Cash bill cum receipt Dt: 21/11/2019
A6- Receipt Dt: 21/11/2019
A7- Medicine Bill
A8- Inpatient bill
A9- Discharge Summary
A10- Laboratory report
B1- copy of the prescription of Dr. Kishor Krishna
X1- Medical records
Witness Examined
Dw1- Kishor Krishna. I
Sd/- Sd/-
MEMBER PRESIDENT
Forwarded by Order
Ps/ Assistant Registrar
