Haryana

Karnal

CC/448/2023

Smt. Rajbala - Complainant(s)

Versus

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

Ram Chander Taya

01 Oct 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.448 of 2023

                                                        Date of instt.07.08.2023

                                                        Date of Decision: 01.10.2024

 

Smt. Rajbala, age about 60 years, wife of Shri Mahinder Singh, resident of village Goeda, Post office Amupur, Tehsil Assandh, District Karnal. Aadhar card no.2457 6499 9691.

                                                                        …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Company Ltd. SCO no.137, 2^nd floor Sector-13, Urban Estate, Karnal through its authorized signatory/person.
2. Star Health and Allied Insurance Company Ltd., New Tank Street, Valluvar Kottam High Road, Nungambakkam Chennai-600034 through its Managing Director.

 

                                                                  …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

 Argued by: Shri R.C. Taya, counsel for the complainant.

                    Shri R.K. Singhal, counsel for the OPs.

 

                     (Jaswant Singh, President)

ORDER:   

                

                  The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that on 13.11.2017, the complainant alongwith her husband obtained the accident and health insurance policy bearing no.P/211114/01/2017 from the OPs, valid from 13.11.2017 to 12.11.2018 and the same was renewed from time to time and finally on 13.11.2022 and paid the premium of Rs.27092/-. The period of insurance was given from 13.11.2022 to midnight of 12.11.2023 basic floater a sum assured Rs.5,00,000/-, bonus Rs.2,00,000/- which are benefit Rs.1,50,000/- and the scheme include two adjusts (i.e. complainant and her husband), limit of coverage Rs.7,00,000/- for hospitalization, pre-hospitalization and post-hospitalization charges. The complainant suffered pain in both the knee associated with stiffness, the pain aggravated by standing for longer duration, exertion and relieved by medicines, rest, the complainant also face difficulty in walking and she was advise knee surgery bilateral total knee replacement. The complainant was medically examined before hospitalization and investigation and diagnostics tests were conducted and the complainant made the payment of Rs.9500/- as per the prescription of the doctor authorized by the OPs. On 03.04.2023, complainant was admitted in Ivy Elite Institute of Orthopedics and Joint Replacement, Ivy Hospital, Super specialty Health Care, Sector-17, Mohali and operated by Dr. Manuj Wadhwa, Mch. (U.K.) , MS and both the knew of the complainant was replaced and she was discharged on 07.04.2023. She was also advised at the time of discharge for manual physical therapy for sixty days under the guidance of physiotherapist, she has spent a sum of Rs.3,30,440/- for the operation of both the knee replacement. The complainant also received the treatment post hospitalization as per the advice of the doctor Manuj Wadhwa, Mch. U.K. MS and she has spent an amount of Rs.1,15,388/- on post hospitalization expenses. The complainant has spent total sum of Rs.4,55,328/- on the operation of knee replacement, which she is entitled as per policy. Complainant lodged the claim with the OPs and submitted all the required documents to settle the claim. OPs paid only Rs.3,63,029/- but did not make the payment of Rs.92,299/- to the complainant and unnecessarily deducted the said amount. Due to this act and conduct of OPs complainant has suffered mental pain, agony and harassment as well as financial loss. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence, complainant filed the present complaint seeking direction to the OPs to pay Rs.92,299/- alongwith interest @ 12% per annum, to pay Rs.50,000/- as compensation to the complainant on account of mental pain and agony and to pay Rs.33000/- towards the litigation expenses.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that a family health optima policy was issued in favour of complainant by OPs, covering Mohinder Singh-self and Raj Bala-spouse for the sum insured of Rs.5,00,000/-. During the subsistence of the insurance policy, the intimation regarding the hospitalization of the complainant was received by the OPs for the treatment of O.A. knee and the complainant remained admitted in the hospital from 02.04.2023 to 06.04.2023. The OPs received the claim bill of Rs.3,30,440/- for cashless payment from the hospital authorities and based on the submitted cashless documents, the claim was processed and an amount of Rs.2,97,336/- was approved and paid to the hospital on 14.04.2023. The insured had further submitted the pre and post treatment documents with the OPs and an amount of Rs.32,589/- was approved and paid to the insured on 15.06.2023 and an amount of Rs.3009/- was approved and paid to the insured on 20.07.2023. The reason for deductions during hospitalization period are;

.       IPD charges not payable hence and amount of Rs.600/- are deducted.

.       Hospital discount Rs.33104/- are deducted.

Hence, maximum payable Rs.297336/- is already paid to the insured, hence Rs.33704/- is not payable.

The reason for the deductions during pre-hospitalization period are;

.       There are no prescription for date 15.03.2023, hence disallowed, Rs.1000/- are deducted.

.       There are stress Echo charges non-payable/no breakup for bill date 15.03.2023, hence 80% payable, hence an amount of Rs.4100/- are deducted.

The reason for the deductions during post hospitalization period are;

.       As per the other excluded expenses of the policy, the charge towards walker, chair, cool pack, kit payable an amount of Rs.10999/- are deducted.

.       As per the other excluded expenses of the policy, the charge towards physio Rs.300/- per day, only 2 weeks payable, an amount of Rs.58200/- are deducted.

Hence, maximum payable Rs.32589/- is already paid to insured. Hence, Rs.74299/- is not payable.

It is further pleaded that again complainant has submitted post documents. On scrutiny of claim documents following are deductions;-As per the other excluded expenses of the policy, the charge towards walking stick non payable/exceed post quantity for PG more medicine, hence disallowed an amount of Rs.1983/- are deducted.

Hence, maximum payable Rs.3009/- is already paid to insured. Hence, Rs.1983/- is not payable. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainants has tendered into evidence affidavit of complainant Ex.CW1/A, copy of aadhar card Ex.C1, copy of letter dated 10.11.2022 regarding approval of renewal of policy Ex.C2, copy of insurance policy Ex.C3, copy of premium receipt Ex.C4, photographs of knee Ex.C5 and Ex.C6, copy of discharge summary Ex.C7, Prescription slip Ex.C8, Doctor opinion Ex.C9, copy of bill assessment sheet Ex.C10, copy of physiotherapy bill Ex.C11, prescription slip Ex.C12, legal fee bill-cum receipt Ex.C13 and closed the evidence on 22.02.2024 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of proposal form Ex.R1, copy of policy schedule Ex.R2, copy of terms and conditions of the policy Ex.R3, copy of IRDA guideline Ex.R4, copy of pre-authorization request Ex.R5, copy of discharge summary Ex.R6, copy of final bill dated 06.04.2023 Ex.R7, copy of claim form Ex.R8, copy of claim form Ex.R9, copy of final bill dated 15.03.2023 Ex.R10,  copy of bill assessment sheet Ex.R11, copy of claim form Ex.R12, copy of bill receipt dated 23.06.2023 Ex.R13, copy of bill assessment sheet Ex.R14 and closed the evidence on 07.03.2024 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant alongwith her husband purchased a health insurance policy from the OPs. Complainant was suffering from knee pain and has taken treatment in Ivy Elite institute of Orthopedics and Joint Replacement, Ivy Hospital, Super specialty Health Care, Sector-17, Mohali and spent Rs.3,30,440/- for replacement of both knees. Complainant also spent an amount of Rs.1,15,388/- on post hospitalization expenses. The complainant submitted the claim of Rs.4,55,328/- for reimbursement but OPs have paid only Rs.3,63,029/- and made deduction of Rs.92,299/- without any cogent reason and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that the insured availed Family Health Optima Insurance Policy from the OPs. The complainant submitted the claim of Rs.4,55,328/- for reimbursement. After considering the claim, an amount of Rs.3,32,934/- was paid and remaining amount was not payable. OPs have rightly deducted the remaining amount as per terms and conditions of the policy and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant was insured under the Family Health Optima Insurance Policy. It is also admitted that complainant has taken treatment for knee replacement from the Ivy Elite institute of Orthopedics and Joint Replacement, Ivy Hospital, Super specialty Health Care, Sector-17, Mohali and submitted the claim of Rs.4,55,328/- for reimbursement. It is also admitted that OPs have paid Rs.3,32,934/- to the complainant and deducted the remaining amount.

11.           The OPs have made deduction of Rs.33104/- on account of discount given by the hospital and paid Rs.2,97,336/- out of Rs.3,31,040/-. Thus, said deduction has rightly been made by the OPs as hospital has given discount of Rs.33104/-.

12.           Complainant also submitted the claim for reimbursement on account of pre-hospitalization, in the said claim Rs.1000/- was deducted by the OPs on account of no prescription for date 15.03.2023. OPs itself placed on file the copy of the said prescription as Ex.R10. Thus, the plea taken by the OPs has no force and said deduction made by the OPs is not justified.

13.           OPs have alleged that the Stress ECHO Charges was not payable and made deduction of Rs.4100/- but OPs have failed to explain as to why the Stress ECHO Charges was not payable. Hence the said deduction is also not justified. OPs have also made a deduction of Rs.10,999/- on account of charging towards the walker, chair, cool pack kit but OPs have also failed to explain as to why the said amount was not payable. OPs have also made a deduction of Rs.58,200/- for physiotherapy but also failed to explain why the said amount was not payable. The deductions made by the OPs is not justified.

 14.          Furthermore, now a days it has become a trend of insurance companies, they issue the policies by giving false assurances and when insured amount is claimed, they make such type of excuses. Thus, the denial of the claim of complainant is arbitrary and unjustified. In this regard, we place reliance on the judgment of Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, wherein the Hon’ble Punjab and Haryana High Court has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

15.           Keeping in view, the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OPs amounts to deficiency in service and unfair trade practice.

16.           Complainant has alleged that she has spent Rs.1,15,388/- on account of post hospitalization whereas OPs have alleged that complainant has submitted the claim of Rs.1,06,888/- only. OPs have paid   only Rs.32,589/- and made deduction of Rs.74299/- without any cogent reason. Hence, the said deduction is appeared to be made by the OPs only on the basis of presumption and assumption, which is not admissible in the eyes of law. Hence, the complainant is entitled for the amount of Rs.74299/- alongwith interest, compensation for mental harassment and litigation expenses etc.   

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.74,299/- (Rs. seventy four thousand two hundred ninety nine only) to the complainant alongwith interest @ 9% per annum from the date of filing the complaint i.e. 07.08.2023 till its realization. We further direct the OPs to pay Rs.15,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 01.10.2024

                                                               

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

(Neeru Agarwal)           (Sarvjeet Kaur)

                   Member                          Member