Karnataka

Kolar

CC/6/2024

Sri.Narayanamma.B - Complainant(s)

Versus

Star Health And Allied Insurance Company Co Ltd - Opp.Party(s)

Arun B.C

31 May 2024

ORDER

Date of Filing: 17/01/2024

Date of Order: 31/05/2024

BEFORE THE KOLAR DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, OLD D.C. OFFICE PREMISES, KOLAR – 563 101.

Dated:31^st DAY OF MAY 2024

SRI. SYED ANSER KALEEM, B.Sc., B.Ed., LL.B., …… PRESIDENT

SMT. SAVITHA AIRANI, B.A.L., LL.M., …..LADY MEMBER

CONSUMER COMPLAINT NO:06/2024

Smt. Narayanamma. B

W/o Varadaraju. T,

Aged about 56 years,

R/at No.453, Kataripalya Main Road,

Opposite Srinivasa Bajane Mandira,

Kolar.

(Rep. by Sri. Arun B. C, Advocate)                      ….Complainant.

  

                                                                                                                - V/s –

1. Star Health & Allied Insurance Company limited.,

No.15, Balaji Complex, white lane,

1^st Floor, Rayapettah,

Chennai-600014.

 

2. The Manager,

Star Health Insurance Co. ltd.,

Kolar Branch, Near New Bustand,

Opposite Saidham Hotel,

Kolar-563101.

(Rep. by Sri. G. R. Ramachandra, Advocate)  ….Opposite Parties.                     

 

-: ORDER:-

BY SMT.SAVITHA AIRANI, LADY MEMBER.,

1. This is the complaint filed under section 35 of the Consumer Protection Act, 2019 against the OPs and prays to direct the Ops to refund the medical bill amount of Rs.29,123/- along with interest 24% P.A and Rs.50,000/- towards compensation in the interest of justice and equity.

 

2. The brief facts of the complaint is that, the complainant had taken the Star Health policy from the OP Insurance Company i.e. Star Health & Allied Insurance Company Limited., Health Policy bearing No. 24642787-1 and the said policy was valid from 27/10/2021 to 26/10/2023.  It is stated that, complainant was admitted in the Srinivasa Nursing Home, for the treatment of Enteric fever with UTI from 31/08/2023 to 04/09/2023. At that time complainant had approached the OP Insurance Company for payment of medical expenses bill issued by the concerned Hospital.  The OP authority requested to pay the above said bill amount to the hospital and subsequently reimburse the same from the OP Insurance Company.  As per the advice of the OP authority, the complainant paid the above said bill amount to the hospital for a sum of Rs. 29,123,00/-.

 

3. Further complainant stated that, the complainant approached the OP Insurance Company for reimbursement of medical claim of the above said amount and submitted all the original Hospital bills to the OP Insurance Company.  It is stated that, despite submitting a claim to OP Insurance Company for medical expenditure.  But the OP Insurance Company repudiated the claim of the complainant on the ground of oral opinion given by their own doctors.  It is alleged that, despite assurance given by the Insurance company as per the terms and conditions the OP delayed the proceedings and ultimately rejected the claim of the complainant. It is stated that, the complainant was got issued the legal notice to OPs on 22/11/2023 through RPAD, though notice duly served to OPs, but OPs have not responded or made any arrangements or settled the claim of the complainant, leaving the matter unresolved.  Hence this complaint.

 

4. On issuance of notice, OP.No.1 & 2 appeared through their counsels and filed their version.

 

5.  In the version OP.No.1 & 2 contended that, the OPs Insurance Company Doctors team opinion, there was no necessity to get treatment as an inpatient.                   The complainant and the treating Hospital i.e Srinivasa Nursing Home in collusion with each other to deceive the OP Insurance Company, though there was no necessity the complainant joined the hospital as inpatient.

 

6. Further OP contended that, as per exclusion-Code Excl-36 of the above said policy, the company is not liable to make any payment under the policy in respect of any hospitalizations which are not medically necessary or does not warrant hospitalization.  Further OP contended that, the complaint is not maintainable either in law or on facts; hence the same is liable to be dismissed in limine.

 

7. In order to prove the case of the parties and both the parties have filed their affidavit evidence along with documents.

 

8. On the basis of the pleading of the parties and the evidence placed on record, the following points will do arise for our consideration:-

1. Whether complainant has proved deficiency in service on the part of the OPs as alleged in the complaint?
2. Whether the complainant is entitled for the relief as sought in the complaint?
3. What Order?

We have heard the arguments of the parties and our answers to above points are as under:

 

 

Point No.(1) & (2):-  Are in the affirmative.

 

Point No(3):-            As per the final order

                               for the following.

 

                                REASONS

 

9. Point No.(1) & (2):-  On perusal of the pleadings of the parties and evidence placed on record and we are of the opinion that these two points are interlinked to each other and in order to avoid repetition of discussion of facts and for the sake brevity these points will taken up together for common discussion.

 

10. On perusing the pleadings of the parties, it is an undisputed facts that, on 27/10/2021 that, the complainant had taken the Star Health Insurance Policy.  It is also not in dispute that, the OP Insurance Company issued Health Insurance Policy bearing No. 24642787-1 and the validity of the said insurance policy is for the period from 27/10/2021 to 26/10/2023.  It is also not in the dispute that, the complainant was admitted to “Srinivasa Nursing Home”, for the treatment of Enteric fever with UTI from 31/08/2023 to 04/09/2023.   It is not in the dispute that, the complainant paid the medical expenditure bill amount to the hospital for a sum of Rs. 29,123,00/-, but the allegation of the complainant is that, the OP Insurance Company (i.e  Star Health & Allied Insurance Co. Ltd.,) repudiated the claim of the complainant after submitting all the original Hospital Bills to the OP insurance company.  As per the terms and conditions of the policy OP Insurance Company did not fulfill their obligation.  The OP.No.1 & 2 contended that, the claim of the complainant was rejected as per the Opinion of the OP Insurance Company Doctors.   The OP Insurance Company Doctors had verified the discharge summary of the complainant and they have come to the conclusion that, “There was no necessity to get treatment as an inpatient”. Hence the claim of the complainant was rejected.

 

11. In order to substantiate the case both parties have filed their affidavit evidence and the complainant filed documents.

 

12. On perusal of the discharge summary and medical records by the complainant it discloses that, on 31/08/2023 complainant was admitted to “Srinivas Nursing Home” for the treatment of Enteric fever with UTI and discharge from the hospital on 04/09/2023 and the said medical bills also discloses that, complainant had incurred an expenditure to an extent of Rs. 29,123/-.  The lab report, consultation record and discharge summery are sufficiently proves that, the complainant had Enteric fever and admitted the above said for treatment on the advice of the doctor who physically examine the complainant.  Hence there is clear corroboration of the pleadings of the complainant and the records as well shown in the discharge summary.  Under these circumstances we cannot disbelieve the case of the complainant in absence of any rebuttable evidence.

 

13. Further on perusal of the Insurance Policy, it is evident that, the complainant is an insured person.  Accordingly the conditions and privileges of the Health Insurance Policy it covers the risks of the health of the insured person who had obtained the above said Health Insurance Policy.

 

14. The main allegation of the complainant is that, When she had approached the OP Insurance Company for claim of the above said medical expenditure of Health insurance policy along with all the original documents which are asked by the OP insurance company, but the Op insurance company has failed to honor the legitimate claim of the complainant only on the basis that, the Op insurance company doctors opinion.  The Op insurance company doctors gave their opinion only on the basis of discharge summary.  On verification of discharge summary of complainant, they come to the conclusion that, the treatment which complainant undergone, admitting for the said treatment in hospital was not necessary. The Op insurance company doctors without physically examine the complainant, simply gave their opinion “i.e. admitting for the said treatment in hospital was not necessary”.  It is well known fact, when there are different doctors available for treatment for the ill health of the complainant, when number of individuals doctors are there, the opinion about the treatment in question is differ from one doctor to other.  The treating doctor is always know how to treat and his line of treatment is obviously different from the insurance doctors, just because the insurance doctors placed certain opinions that cannot be considered as gospel truth to believe that, and to accept their opinions in absence of cogent evidence.

 

15. It is worth to note that, the OP insurance company failed to produce any authentic document to show that, “the complainant admitting for the said treatment in hospital was not necessary”, which the opinion was given by their own company doctors.  Hence in absence of cogent evidence the contention raised by the OP insurance company is not acceptable one.  Under these circumstances, when policy in force and the complainant suffered by the fever  and the complainant admitted  for the above said treatment on the advice of the doctor who physically examine the complainant. The complainant incurred medical expenditure and as per the coverage of the policy, it is bounden duty of the insurer to settle the legitimate claim of the insured and not doing so, it is clear deficiency in service on the part of the OPs Insurance Company.  

 

16. On looking into the ground of repudiation of the claim of the complainant, that ground taken by the OP Insurance Company is nothing but a mere technical ground and in absence of cogent evidence the ground urged by the OP insurance company appears to be flimsy ground and same cannot be acceptable one. Under these circumstances we deem it just and proper that, the complainant is entitled for a sum of Rs.29,123/-towards medical expenditure incurred.  Further Op insurance company not settled the claim of the complainant well in time and hence complainant is entitled for interest @ 6% from the date of repudiation till the realization along with Rs.2,000/-towards the cost of proceedings.  Accordingly we answered these two Point No. (1) & (2) are in the Affirmative.

 

17.  Point No. (3):- On the basis of discussion and reasons assigned while answering Point No.(1) and (2) and thereon we proceed to pass the following order:

 

 

 

 

6698606.  

1. The complaint is hereby allowed with cost.
2. Further OP Insurance Company i.e “Star Health and Allied Insurance Company limited” represented by its Manager is directed to pay Rs.29,123/-along with interest @ 6% from the date of repudiation till its realization.
3. Further OP is directed to pay Rs.2,000/- towards cost of proceedings.
4. Further OP Insurance Company is directed to submit compliance report within 45 days from the date of this Order.
5. Send a copy of this order to all the parties to the proceedings at free of cost.

 

             (Dictated to the Stenographer, transcribed by him, corrected and then pronounced by us on this 31^st DAY OF MAY 2024)

 

 

        MEMBER                                  PRESIDENT