| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KOZHIKODE PRESENT: Sri. P.C. PAULACHEN, M.Com, LLB : PRESIDENT Smt. PRIYA.S, BAL, LLB, MBA (HRM) : MEMBER Sri.V. BALAKRISHNAN, M Tech, MBA, LL.B, FIE: MEMBER Thursday the 24th day of October 2024 CC.157/2020 Complainant Deepak. P.R, Chevayur. P.O, Chevayur .P.O, Kozhikode - 673017 Opposite Party Star Health and Allied Insurance Co. Ltd, Branch Office No. 10/124 E, PM Taj Road, 1st Floor, Alisa Mall, SM Street, Calicut – 673001 (By Adv. Sri. L.S. Bhagaval Das) ORDER By Smt. PRIYA. S - MEMBER This is a complaint filed under Section 35 of the Consumer Protection Act, 2019. - The case of the complainant, in brief, is as follows:
As per claim No. CLI/2021/181311/0098427 the complainant’s Hospitalization Bill is Rs. 85,673.37/-. This is a cashless treatment. Yet the complainant had to pay Rs. 11,666/- to the hospital. - The opposite party has been deducted Rs. 2,000/- under the head of room rent. Under the head of professional fee and surgeon fee Rs. 1,300/- has been deducted. Blood Sugar Investigation Rs. 100/- has also been deducted. Under the head of medicines Rs. 8,000/- and under the head of others Rs. 250/- have been deducted.
- Apart from the above mentioned, doctor’s follow up charges was deducted.
Rs. Ps. Consultation Fee 250.00 Lab test 2710.00 Medicines Bill1 45.00 Medicines Bill 529.70 _____________________ 3,634.70 The amount remitted in hospital 11,666.00 ______________________ Total 15,300.00 _________________________ - The complainant got Rs. 3,797/- as reimbursement from the opposite party. Complainant prays for Rs. 11,503/- as reimbursement from the opposite party. Complainant prays for Rs. 11,503/- as reimbursement from the opposite party.
- The opposite party has filed version. As per the version it is submitted that the complainant had taken a Family Health Optima Insurance Policy from the opposite party on 28/03/2013 and the same has been renewed up to 27/03/2021 for a sum insured of Rs. 5,00,000/- vide policy No. P/181311/01/2020/066582. At the time of availing the policy the complainant was supplied with the terms and conditions of the policy. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the policy schedule. Moreover it is clearly stated in the policy schedule “the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc attached”.
- The opposite party had received a pre-authorization request for cashless hospitalization from Baby Memorial Hospital, Kozhikode stating that the complainant was admitted at the hospital on 13/06/2020 and was provisionally diagnosed with Inguinal Hernia.
- Based on the records and bills forwarded by the hospital, the opposite party, had processed the claim and had authorized an amount of Rs. 74,007/- as cashless authorization out of the hospitalization expenses of Rs. 85,673/- and the same was informed to the hospital vide letter dated 18/06/2020.
- After discharge from the hospital, the complainant had approached the opposite party claiming for the balance of the amount as reimbursement. After receiving the documents, the opposite party had processed the claim and approved an amount of Rs. 3,093/- and the same was credited to the account of the complainant on 01/08/2020.
- After receiving the complaint from the Commission, the opposite party has again reprocessed the claim and considered the admissible amount and hence the opposite party is ready to give an amount of Rs. 5,837/- to the complainant. All deductions were made as per policy terms and conditions. The complainant is not entitled to get Rs. 11,503/-. The opposite party prays to dismiss the complaint with costs to the opposite party.
- The points that arise for determination in this complaint are;
- Whether there was any deficiency of service or unfair trade practice on the part of the opposite party, as alleged?
- Reliefs and costs.
- Evidence in this case consists of oral evidence of PW1 and Exts A1 to A3 on the side of the complainant and Ext B1 on the side of the opposite party.
- Heard.
- Point No.1: In order to substantiate the allegation, the complainant got himself examined as PW1, who has deposed in terms of the averments in the complaint and in support of the claim. Ext A1 is the policy card, Ext A2 is the policy copy and Ext A3 is the Hospital Bills and Ext B1 is the Bill Assessment Sheet.
- The grievance projected in the complaint is that as per claim No. CLI/2021/181311/0098427 the complainant’s Hospitalization Bill is Rs.85,673.37/-. This is a cashless treatment. Yet the complainant had to pay Rs.11,666/- to the hospital.
- The opposite party has been deducted Rs. 2,000/- under the head of room rent. Under the head of professional fee and surgeon fee Rs. 1,300/- has been deducted. Blood Sugar Investigation Rs. 100/- has also been deducted. Under the head of medicines Rs. 8,000/- and under the head of others Rs. 250/- have been deducted.
- Apart from the above mentioned, doctor’s follow up charges was deducted.
Rs. Ps. Consultation Fee 250.00 Lab test 2710.00 Medicines Bill1 45.00 Medicines Bill 529.70 _____________________ 3,634.70 The amount remitted in hospital 11,666.00 ______________________ Total 15,300.00 _________________________ - The complainant got a Rs. 3,797/- as reimbursement from the opposite party. Complainant prays for Rs. 11,503/- as reimbursement from the opposite party.
- Going by the version of the opposite party, it can be seen that the complainant had taken a Family Health Optima Insurance Policy from the opposite party on 28/03/2015 and the same has been renewed up to 27/03/2021 for a sum insured of Rs. 5,00,000/- vide Policy No. P/181311/01/2020/006582. At the time of availing the policy the complainant was supplied with the terms and conditions of the policy. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the policy schedule. It is clearly stated in the policy schedule “ the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc attached”.
- On the basis of pre-authorization request for cashless hospitalization from Baby Memorial Hospital, Kozhikode stating that the complainant was admitted at the hospital on 13/06/2020 and was provisionally diagnosed with Inguinal Hernia. Based on the records and bills, the opposite party had processed the claim and had authorized the claim and had authorized Rs.74,007/- as cashless authorization out of the hospital expenses of Rs.85,673/- and the same was informed to the hospital vide letter dated 18/06/2020.
- Discharged from the hospital, the complainant had approached the opposite party claiming for the balance of the amount as reimbursement. After receiving the documents, the opposite party had processed the claim and approved an amount of Rs. 3,093/- and the same was credited to the account of the complainant on 01/08/2020.
- After receiving the complaint from the Commission, the opposite party has again reprocessed the claim and considered the admissible amount and hence the opposite party is ready to give an amount of Rs. 5,837/- to the complainant. The complainant is not entitled to Rs. 11,503/-.
- Ext A2 document (policy copy) page No. 2 reveals that the period of insurance is from 28/03/2020 to 27/03/2021. In page No.2 of version it is written that the complainant was admitted at the hospital on 13/06/2020 and was provisionally diagnosed with Inguinal Hernia. So it is clear that the incident happened well within the time limit of insurance coverage. This is an undisputed fact.
- The dispute is only with regard to the quantum of reimbursement. In PW1’s deposition it is stated that he was admitted in the hospital on 13/06/2020 Rs.85,673/- was the actual hospital charges in total. But the opposite party approved Rs. 74,007/-. Apart from that Rs. 3,797/- was received as reimbursement. Complainant remitted Rs. 11,666/- in the hospital. The opposite party also offered to give Rs. 5,837/- to the complainant as reimbursement. But the complainant is not ready to accept Rs. 5,837/-. The complainant is demanding for a reimbursement of Rs. 11,503/-.
- It is vivid from Ext A3 document that the complainant had remitted Rs.11,666/- to the hospital on 18/06/2020 itself. Rs. 2,710/- was also remitted on 24/06/2020. Rs. 529.70/- was remitted for medical bill on 18/06/2020. There is no document to show that the complainant has remitted Rs. 250/- under the head of consultation fee and Rs. 145/- under the head of medicine bill.
- After perusing Exts A1, A2, A3 and B1 documents, it can be inferred that
Rs. 11,503 – Rs. 395 = Rs. 11,108/- is the amount which should be reimbursed to the complainant by the opposite party. - After perusing oral and documentary evidence in this case, we are of the view that there is deficiency of service and unfair trade practice from the part of the opposite party. The complainant is eligible to get a reimbursement of Rs. 11,108/- from the opposite party.
- Point No. 2: In the light of the finding on the above point, the complaint is disposed of as follows:
- CC 157/2020 is allowed in part.
- The opposite party is directed to pay Rs. 11,108/-(Rupees eleven thousand one hundred and eight only) to the complainant with interest @ 9% from the date of this order till actual payment.
- The order shall be complied with within 30 days of the receipt of copy of this order.
- No order as to costs.
Pronounced in open Commission on this, the 24th day of October, 2024. Date of Filing: 12/08/2020 Sd/- Sd/- Sd/- PRESIDENT MEMBER MEMBER APPENDIX Exhibits for the Complainant : Ext.A1 – Policy card. Ext.A2 – Policy copy. Ext.A3 – Hospital Bills. Exhibits for the Opposite Party Ext.B1 – Bill Assessment Sheet. Witnesses for the Complainant PW1 - Deepak. P.R (Complainant) Sd/- Sd/- Sd/- PRESIDENT MEMBER MEMBER True Copy, Sd/- Assistant Registrar. | |
