DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/123/2022
Date of Institution: 18.04.2022
Date of Decision: 28.06.2024
Sh. Manoj Mittal son of Vijay Mittal resident of H.No. B-III-257/A, Near Geeta Bhawan, Backside Visit Hotel, Barnala, Tehsil and District Barnala.
…Complainant
Versus
1. Star Health and Allied Insurance Company Limited, New Tank Street, Valluvar Kottam High Road, Nungambakam, Chennai-600034 through its Manager/Authorized Signatory.
2. Star Health and Allied Insurance Company Limited, 2nd floor, above Delhi Tractor & Combines, Opposite PNB Bank, College Road, Barnala-148101 through its Manager/Authorized Signatory.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Varun Singla Adv counsel for complainant.
Sh. Rohit Jain Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover : President
2. Sh. Navdeep Kumar Garg : Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Star Health and Allied Insurance Company Limited & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant is the permanent resident of Barnala and one of the official/agent of opposite party contacted the complainant and told about their various insurance schemes. On believing the words, the complainant agreed to purchase YOUNG STAR INSURNACE POLICY and the complainant alongwith his family (wife namely Rashmi Mittal and two children namely Kapish Mittal and Gorisha) were medically examined. Thereafter, the complainant paid an amount of Rs. 21,182/- and opposite parties issued one policy No. P/211229/01/2021/000352 and the complainant continued the said policy regularly without any discrimination and paid the premium amount of Rs. 21,182/- for year 2021-2022 and issued Renwal Endorsement No. P/211229/01/2022/000856 and the sum of Rs. 10,00,000/- was insured under the said policy. It is further alleged that during the subsistence of the policy, in the month of October 2021 the complainant started facing Health issues and thereby went to Punjab Computerised Laboratory, Barnala dated 22.10.2021 for diagnosis in which the problem of Dengue came and on 23.10.2021 the complainant was taken to Sidhu Hospital & Heart Centre, Barnala for treatment, but with no result and the complainant was charged with Rs. 4,481/-. Subsequently, the complainant was taken to Aashta Hospital, Barnala where the complainant remained admitted from 26.10.2021 to 28.10.2021 where an expenditure of Rs. 18,885/- was made and was scanned at Pandhi Scan Centre where an amount of Rs. 2,500/- was spent and when the complainant’s health condition was getting worst he was referred to Dayanand Medical College & Hospital, Ludhiana by Ambulance charging Rs. 2,500/- for his treatment dated 28.10.2021 where the complainant was admitted and was discharged on 30.10.2021 and was charged Rs. 22,940/-. Therefore, a total expenditure of Rs. 56,306/- has been spent on the treatment of the complainant. It is further alleged that the complainant approached the opposite party No. 2 for the medical claim which is covered under the policy and the complainant submitted all the original documents as said by them and opposite party No. 2 assured that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week. Thereafter, after fully harrying the complainant on one pretext of the other, opposite parties gave only Rs. 33,668/- to the complainant out of Rs. 56,306/- and assured to pay the remaining amount in a few days. Thereafter, the complainant reported the matter to the opposite parties several times but the opposite parties putting off the matter on one pretext or the other. As such, there is deficiency in service on the part of the opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to pay the remaining amount of Rs. 22,638/-.
- To pay Rs. 50,000/- on account of compensation for causing mental torture, agony and harassment to the complainant.
- Further, to pay Rs. 10,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections interalia on the grounds that the complainant has no locus-standi to file the present complaint. The present complaint is not legally maintainable. The complainant dragged the opposite parties in false litigation. The complainant has not come with clean hands and complainant suppressed the material facts from this Commission.
4. On merits, it is admitted to the extent that the complainant alongwith his family i.e. wife and two children got medical insurance policy and the complainant paid premium of Rs. 21,182/- and policy No. P/211229/01/2021/000352 was issued to the complainant and the complainant got same renewed by paying premium of Rs. 21,182/- for the year 2021-2022 and renewal endorsement No. P/211229/01/2021/000856 was issued for total insured sum of Rs. 10,00,000/-. It is further admitted to the extent that as told by the complainant that in October 2021 the complainant started facing health problem and was taken to different hospitals and remained admitted and spent a total amount of Rs. 56,306/- on his treatment. It is further alleged that the complainant submitted claim form alongwith original bills and after scrutiny of all the documents and as per terms and conditions of the policy an amount of Rs. 33,668/- was paid to the complainant. It is denied that the opposite parties assured the complainant that they will pay the remaining amount. It is further alleged that as per the other Excluded Expenses No. 52 of the policy, the charges pertaining to Extra Nursing Charges of Rs. 200/- are not payable. Further, as per the other Excluded Expenses No. 25 of the policy, the charges pertaining to DIETCIAN of Rs. 110/- are not payable. It is further submitted that as per the other Excluded Expenses of the policy, the charges pertaining to RBS, TRIAGE STRIP (which is a non medical item) not payable. As per the test Rs. 600/- is the maximum payable amount. Hence, an amount of Rs. 1820/- are not payable and deducted. As per the other Excluded Expenses of the policy, the charge towards VOLUFIX, PLASTIC TRAY (non medical item) are not payable. Hence, an amount of Rs. 162/- was deducted. As per the other Excluded Expenses of the policy, the charge towards PULSE OXYMETER (No. 37). Further, as per the exclusion clause No. 34 MISC CHARGES and ADMISSION FEE are not payable, hence an amount of Rs. 1,460/- are not payable. That the hospital discount, which is not paid by the insured is not reimbursable. Hence, an amount of Rs. 4,150/- was deducted. It is further submitted that there is no cash paid seal in medicine charges in AASTHA MEDICINE, hence the same are not payable, hence an amount of Rs. 7,546/- are deducted. There are BILL dated 26.10.2021 to 28.10.2021 of AASTHA HOSPITAL, however the insured has not furnished the CASH PAID RECEIPT, hence the same is no payable and Rs. 10,820/- are deducted. Further, as per the other Excluded Expenses of the policy, the charge towards MEDICAL CERTIFICATE CHARGES are NOT PAYABLE, hence Rs. 220/- are deducted. It is further submitted that the total amount was Rs. 60,156/-, deduction Rs. 22,338/-, hospital discount Rs. 4,150/- and total payable amount Rs. 33,668/- and the same is already paid to the insured as per terms and conditions of the policy. All other allegations are denied and prayed for the dismissal of complaint.
5. The complainant filed rejoinder to the written version filed by the opposite parties vide which the complainant denied the averments as mentioned in the written version.
6. To prove the case the complainant tendered into evidence affidavit of complainant Ex.C-1, copy of insurance policy Ex.C-2 dated 9.9.2020 (containing 8 pages), copy of insurance policy Ex.C-3 dated 30.9.2021 (containing 4 pages), copy of lab reports Ex.C-4 (containing 3 pages), copy of prescription slip Ex.C-5 ( containing 2 pages), copy of lab report dated 23.10.2021 Ex.C-6 (containing 2 pages), copy of tax invoice Ex.C-7 dated 25.10.2021 Ex.C-7, copies of lab report Ex.C-8 to Ex.C-12, copy of bill dated 27.10.2021 Ex.C-13, copy of prescription slip dated 28.10.2021 Ex.C-14 (containing 2 pages), copy of MRI dated 28.10.2021 Ex.C-15 (containing 5 pages), copy of lab test dated 28.10.2021 Ex.C-16, copy of receipt dated 28.10.2021 Ex.C-17, copy of medical bill dated 28.10.2021 Ex.C-18, copy of hospital bill dated 28.10.2021 Ex.C-19, copies of bills and receipt Ex.C-20 to Ex.C-42, copy of discharge summary Ex.C-43 (containing 3 pages), copy of Final bill Ex.C-44 (containing 2 pages), copy of detail bill dated 30.10.2021 Ex.C-45 (containing 3 pages), copy of legal notice Ex.C-46, postal receipts Ex.C-47 & Ex.C-48, copy of adhaar card Ex.C-49 and closed the evidence.
7. To rebut the case the opposite parties tendered into evidence affidavit of Sumit Kumar Ex.O.Ps-1 copies of terms and conditions Ex.O.Ps-2 (containing 7 pages), copy of policy Ex.O.Ps-3 (containing 4 pages), copy of proposal form Ex.O.Ps-4 (containing 4 pages), copy of probability form Ex.O.Ps-5, copy of field visit report Ex.O.Ps-6 (containing 3 pages), copy of IRDA guidelines Ex.O.Ps-7 (containing 10 pages), copy of request of cashless Ex.O.Ps-8 (containing 5 pages), copies of letters Ex.O.Ps-9 & Ex.O.Ps-10, copy of claim form Ex.O.Ps-11 (containing 4 pages), copy of authorization letter Ex.O.Ps-12, copy of discharge summary Ex.O.Ps-13 (containing 3 pages), copies of bills Ex.O.Ps-14 & Ex.O.Ps-15, copy of assessment sheet Ex.O.Ps-16 (containing 6 pages) and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file.
9. It is admitted case of the complainant that the complainant alongwith his family i.e. wife and two children got medical insurance policy and the complainant paid premium of Rs. 21,182/- and policy No. P/211229/01/2021/000352 was issued to the complainant and the complainant got same renewed by paying premium of Rs. 21,182/- for the year 2021-2022 and renewal endorsement No. P/211229/01/2021/000856 was issued for total insured sum of Rs. 10,00,000/- (as per Ex.C-2 & Ex.C-3). It is also admitted fact by the opposite parties that in the month of October 2021 the complainant started facing health problem and was taken to different hospitals and remained admitted and spent a total amount of Rs. 56,306/- on his treatment and the complainant submitted claim form alongwith original bills and after scrutiny of all the documents and as per terms and conditions of the policy an amount of Rs. 33,668/- was paid to the complainant.
10. The case of the complainant is that during the subsistence of the policy, in the month of October 2021 the complainant started facing Health issues and thereby went to Punjab Computerised Laboratory, Barnala dated 22.10.2021 (Ex.C-4) for diagnosis in which the problem of Dengue came and on 23.10.2021 (Ex.C-5) the complainant was taken to Sidhu Hospital & Heart Centre, Barnala for treatment and the complainant was charged with Rs. 4,481/-. Thereafter, the complainant was taken to Aashta Hospital, Barnala where the complainant remained admitted from 26.10.2021 to 28.10.2021 (Ex.C-19), where an expenditure of Rs. 18,885/- was made and was scanned at Pandhi Scan Centre where an amount of Rs. 2,500/- was spent (Ex.C-20). Further, when the complainant’s health condition was getting worst he was referred to Dayanand Medical College & Hospital, Ludhiana by Ambulance charging Rs. 2,500/- for his treatment dated 28.10.2021 (Ex.C-21), where the complainant was admitted and was discharged on 30.10.2021 and was charged Rs. 22,940/- (as per Ex.C-44), therefore a total expenditure of Rs. 56,306/- has been spent on the treatment of the complainant. It is further alleged by the complainant in the complaint that the complainant approached the opposite party No. 2 for the medical claim which is covered under the policy and submitted all the original documents as said by them and opposite party No. 2 assured that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week. The allegation of the complainant is that the opposite parties gave only Rs. 33,668/- to the complainant out of Rs. 56,306/- and assured to pay the remaining amount in a few days, but thereafter the opposite parties putting off the matter on one pretext or the other.
11. On the other hand, the stand of the opposite parties is that after scrutiny of all the documents and as per terms and conditions of the policy an amount of Rs. 33,668/- was paid to the complainant. It is further alleged by the opposite parties in the written version that as per the other Excluded Expenses No. 52 of the policy, the charges pertaining to Extra Nursing Charges of Rs. 200/- are not payable and as per the other Excluded Expenses No. 25 of the policy, the charges pertaining to DIETCIAN of Rs. 110/- are not payable. It is further alleged by the opposite parties in the written version that as per the other Excluded Expenses of the policy, the charges pertaining to RBS, TRIAGE STRIP (which is a non medical item) not payable and as per the test Rs. 600/- is the maximum payable amount, hence, an amount of Rs. 1820/- are not payable and deducted and as per the other Excluded Expenses of the policy, the charge towards VOLUFIX, PLASTIC TRAY (non medical item) are not payable, hence an amount of Rs. 162/- was deducted. It is further alleged by the opposite parties in the written version that as per the exclusion clause No. 34 MISC CHARGES and ADMISSION FEE are not payable, hence an amount of Rs. 1,460/- are not payable and the hospital discount, which is not paid by the insured is not reimbursable, hence an amount of Rs. 4,150/- was deducted. It is further submitted by the opposite parties that there is no cash paid seal in medicine charges in AASTHA MEDICINE, hence the same are not payable and an amount of Rs. 7,546/- are deducted and there are BILL dated 26.10.2021 to 28.10.2021 of AASTHA HOSPITAL, however the insured has not furnished the CASH PAID RECEIPT, hence the same is no payable and Rs. 10,820/- are deducted. It is further alleged by the opposite parties in the written version that as per the other Excluded Expenses of the policy, the charge towards MEDICAL CERTIFICATE CHARGES are NOT PAYABLE, hence Rs. 220/- are deducted and the total amount was Rs. 60,156/-, deduction Rs. 22,338/-, hospital discount Rs. 4,150/- and total payable amount Rs. 33,668/- and the same is already paid to the insured as per terms and conditions of the policy. But the opposite parties have failed to explain/clarify by producing any cogent and reliable evidence on record that how they have deducted the above said amount from the claiming amount of the complainant and paid the amount of Rs. 33,668/- only to the complainant.
12. In order to prove the case the complainant has placed on record copy of Bill No. 2213 dated 28.10.2021 Ex.C-19 of AASHTA HOSPITAL, BARNALA which shows that an amount of Rs. 10,820/- has been spent by the complainant on his treatment. The complainant has also placed on record copy of Final Bill dated 30.10.2021 Ex.C-44 of Dayanand Medical College & Hospital Ludhiana, which shows that the complainant has spent an amount of Rs. 22,940/- on his treatment. The complainant further placed on record copies of bills of medicines i.e. Ex.C-7, Ex.C-13, Ex.C-17, Ex.C-18, Ex.C-20, Ex.C-21, Ex.C-23 to Ex.C-25, Ex.C-27, Ex.C-28, Ex.C-30, Ex.C-31, Ex.C-36, Ex.C-38 & Ex.C-39, Ex.C-40, Ex.C-41 and Ex.C-42 which comes to the tune of Rs. 19,658/-. So, the total amount comes to the tune of Rs. 53,418/- (i.e. Rs. 10,820 + Rs. 22,940 + Rs. 19,658 = Rs. 53,418/-). It is admitted by the complainant that the opposite parties have paid Rs. 33,668/- to the complainant. The opposite parties have not given the valid reason of deductions as mentioned in the written version. Ld. Counsel for the complainant argued that the opposite parties have deducted the amount for which the complainant is entitled without any justification. Ld. Counsel for complainant further argued that the opposite parties had not supplied the terms and conditions of the policy to the complainant. We have carefully gone through the entire facts and evidence produced by the opposite parties. The opposite parties have failed to prove that the terms and conditions of the policy were supplied to the complainant. So, we are of the view that the complainant is now entitled to the tune of Rs. 19,750/-, as the deduction made by the opposite parties are not justified. However, the complainant in his complaint has alleged that a total expenditure of Rs. 56,306/- has been spent by him on his treatment and the complainant demanded the remaining claim amount of Rs. 22, 638/- from the opposite parties. But after going through the file carefully we are of the view that the complainant is entitled to Rs. 19,750/- only as per above said bills. So, from the above discussion, it is proved that there is deficiency in service & unfair trade practice on the part of the opposite parties as the opposite parties deducted the amount wrongly.
13. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 19,750/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 5,500/- on account of mental agony and harassment and Rs. 3,300/- on account of litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
28th Day of June, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
