Karnataka

Bangalore 4th Additional

CC/668/2017

Mr.Jayavittal Rao Kolar, - Complainant(s)

Versus

Star Health and Allied Insurance Company Ltd., - Opp.Party(s)

Arun Kumar and others

06 Mar 2020

ORDER

Complaint Filed on:13.04.2017

Disposed On:06.03.2020

                                                                              

BEFORE THE IV ADDL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H ROAD, SHANTHINAGAR, BENGALURU – 560 027.

 

 

 

 

 

06^thDAY OF MARCH 2020

 

PRESENT

SMT.PRATHIBHA. R.K., BAL, LLM - PRESIDENT

SMT.N.R.ROOPA, B.A., LLB, MEMBER

SRI.SURESH.D., B.Com., LL.B. MEMBER

 

 

COMPLAINT No.668/2017

 

 

COMPLAINANT	Mr.Jayavittal Rao Kolar, S/o Late Kolar Rama Rao, Aged about 72 years, Senior Advocate, Office:Ramanashree Complex, F-3, 654/13, 46th Cross, 3rd Block, Rajajinagar, Bangalore – 560010.   Advocate – ShubhangSetlur.       V/s
OPPOSITE PARTy	Star Health &Allied Insurance Company Ltd., “Esteem Tower”, No.71, III Floor, Railway Parallel Road, Kumara Park West, Bangalore – 560 020.   Represented by its Authorized Signatory.   And having Corporate Grievance Department, At No.1, New Tank Street, Valluvarkottam High Road, Nungumbakkam, Chennai – 600034.   Advocate – Sri.Y.PVenkatapathi

 

ORDER

 

SMT.PRATHIBHA. R.K., PRESIDENT

 

The complainant has filed this complaintU/s.12 of the Consumer Protection Act, 1986against Opposite Party (herein after referred as OP) with a prayer to direct OP to pay a sum of Rs.50,025/- being the difference between Rs.2,10,000/- (payable amount) and Rs.1,59,975/- (amount paid) with interest @ 18% p.a from 27.10.2016 till the date of payment, to pay a sum of Rs.10,00,000/- towards the mental stress and agony caused to the complainant and towards damages, to pay Rs.1,00,000/- towards legal cost and such other reliefs.

 

2. The brief allegations made in the complaint are as under:

 

 

Complainant availed “Senior Citizens Red Carpet Health Insurance Policy” bearing Policy No.P/111113/01/2015/015720 dated 24.03.2015 with the OP.  The policy sum insured was of Rs.3,00,000/-.  The complainant submitted that at the time of obtaining the policy he has disclosed pre-existing disease was Hypertension.  The same was renewed for a period from 24.03.2016 to 23.03.2017 vide policy bearing No.P/1111113/01/2016/014956.

 

The complainant submitted that on 24.10.2016 complainant having a discomfort and advised to undergo an angiogram at Fortis Hospital, Cunningham Road, Bangalore.  As per the advice of the doctor, complainant undergone Angiogram on 24.10.2016.  As Angiogram showed certain blocks, hence complainant underwent Angioplasty and discharged from the hospital on 27.10.2016.  At the time of admission to the hospital, complainant intimated the claim to the OP vide No.CLI/2017/111113/0270080.  For the above said treatment, the complainant incurred a sum of Rs.5,52,444/-.  Therefore the complainant is entitled to the entire amount covered by the insurance policy.

 

Complainant further submitted that the complainant having no pre-existing illness, hence the complainant is liable to co-pay 30% of the amount out of Rs.3,00,000/-.  Out of Rs.3,00,000/-  the complainant is liable to make a payment of Rs.90,000/- and the OP is required to make payment of Rs.2,10,000/- towards the expenses incurred by the complainant.  Further the OP disallowed various other charges on vague grounds vide its letter dated 27.10.2016 although all those are covered by the policy.  The OP is trying to reduce its liability by resorting to unnecessary deductions which are not justified in any manner whatsoever.  This act of OP completely unfair trade practice.  The OP has admitted only a sum of Rs.2,37,000/- out of the total bill amount of Rs.5,52,444/-.  It is further submitted that in case of no pre-existing illness, the co-payment is only 30% as per the terms and conditions of the policy.  But the OP imposed 50% of the entire amount as co-payment as if there was some pre-existing illness and admitted only Rs.1,18,500/- and made payment of only Rs.1,12,575/- towards hospital expenses.  Hence complainant issued notice dated 16.11.2010 to the OP that he is not liable to make 50% co-payment, hence requested to return of 20% of the amount that they have collected.

 

Complainant further submitted that Dr.Gopi, the Interventional Cardiologist has confirmed in no uncertain terms that he has no history of cardiac problems or no past history of IHD vide his letter dated 21.12.2016.  The OP requested for a TMT report of the year 2013 vide its letter dated 07.01.2017.  The complainant sent across the TMT report vide letter dated 30.01.2017.  The TMT report very clearly indicated that there was no heart ailment.  OP addressed a letter dated 20.01.2017 stating that it has settled the maximum amount and that there was no further amount of payment under the policy for the said claim.

 

Complainant further submitted that OP had treated the complainant as having a pre-existing disease and had refused to make payment of the entire amount due.  OP is required to admit the entire bill and is liable to make payment of the entire amount covered by the insurance policy subject to any co-payment obligations.  Hence complainant issued legal notice on 01.03.2017 calling upon the OP to pay Rs.97,425/- being the difference between Rs.2,10,000/- (payable amount) and Rs.1,12,575/- (amount already paid) with interest @ 18% p.a from 27.10.2016 till the date of payment.  After receipt of the legal notice OP changed its stand and without referring to the said legal notice and the various rejections that proceeded the legal notice made a payment of Rs.47,400/- vide cheque bearing No.950002 dated 18.03.2017.  OP is required to admit the entire bill and is liable to make payment of entire amount covered by the insurance company.    The OP has once again made a payment to the complainant towards 20% extra co-payment collected by them but they failed to admit the original bill of Rs.5,52,444/- and pay the entire amount covered by the policy.  Hence OP is liable to pay remaining balance amount of Rs.50,025/-.  Complainant further submitted that OP is not admitting the entire bill has subjected to the complainant herein to further trauma and harassment are also liable to compensate the complainant.  Hence complainant filed this complaint.

 

3. In response to the notice issued, OP appeared through their advocate and filed their version contending in brief, as under:

 

Complainant has taken the alleged policy from the OP and the complainant has failed to state the said policy is conditional and the rights and obligations are guided as per the premium and terms and conditions of the policy.  The said policy has been issued with certain defined limits in respect of the certain ailments and also certain expenses incurred by the insured.  The complainant suppressed the facts and has filed the complaint, hence, the complainant has been admitted as the claim of the complainant is processed as per the terms and conditions and the allowable amounts since have been received by him unconditionally.  The OP further submitted that there is no deficiency on the part of OP.  OP settle the claim based on the obligations as per the terms and conditions of the policy has paid the amount.  The same is the maximum amount payable to the complainant as per the policy terms and conditions.  Further the amount assessed in the manner that, “The amount claimed – 30% of the claim and other non-payables (like non medical and restricted obligated amounts = amount payable.  Thus the claim was made assumingly for Rs.3,00,000/- then also the other non-payables also taken into consideration in assessing the obligation of the OP, which the complainant has failed to notice.  Hence, with misconception the above complaint filed by the complainant.

 

OP Further submitted that OP has evaluated the claim based on the copies of the documents.  Hence, when the claim is scrutinized based on the documents, the same will not be deficiency of service.  Hence the complainant is deficient in service.

 

Further OP submitted that the complainant has filed this complaint after receiving the amount which amounts to illegal and not maintainable.  OP is not liable to make payment of the amount claimed against the various heads or costs or interest.  The complainant accepted the amount unconditionally and also got the cheque encashed.  Hence OP prays for dismissal of the complaint.

 

4. In the course of enquiry into the complaint, the complainant and the OP have filed their affidavit reproducing what they have stated in their respective complaint and objections.  Complainant has produced certain documents.We have heard the arguments of complainant and OP and we have gone through the oral and documentary evidence of both parties scrupulously and posted the case for order.

 

5. Based on the above materials, the following points arise for our consideration;

 

 

1. Whether the complainant has proved that there is deficiency in service on the part of the OP, if so, whether complainant is entitled for the relief sought for?

 

 

2.  What order?

 

6. Our findings on the above points are as under:

 

Point No.1:  Negative

Point No.2:  As per the order below

REASONS

 

 

7.Point No.1:-Admittedly the complainant availed ‘Senior Citizens Red Carpet Health Insurance Policy’ bearing No.P/111113/01/2015/01570 on 24.03.2015 with the OP for sum assured of Rs.3,00,000/-.  The said insurance policy was renewed from 24.03.2016 to 23.03.2017 bearing policy No.P/1111113/01/2016/014956.  It is also admitted fact that at the time of inception of the policy, complainant had disclosed that he has having hypertension.

 

8. On 24.10.2016 complainant felt discomfort hence he has admitted to Fortis Hospital, Cunningham Road, Bangalore and undergone an angiogram.  The doctor advised the complainant for the Angioplasty since angiogram shows certain blocks.  The complainant undergone an angioplasty and discharged from the hospital on 27.10.2016.  For the above said treatment the complainant spent a sum of Rs.5,52,444/-, the OP has settled only Rs.1,12,575/- by deducting 50%of co-pay.  In this regard the complainant approached the OP for deduction of 50% of co-pay.  The OP has refunded Rs.47,400/-.  The complainant alleges that the complainant had insured a sum of Rs.3,00,000/- after deducting the 30% of co-pay, he is entitled for Rs.2,10,000/-.  But OP has paid only an amount of Rs.1,65,900/-, the balance amount of Rs.50,025/- has not paid. 

 

9. Per contra OP submitted that the OP has evaluated the claim based on the copies of the documents.  As per the policy terms and conditions the amount will be assessed in the manner that, “The amount claimed – 30% of the claim and other non-payables (like non medical and restricted obligated amounts = amount payable”.  Accordingly the OP has paid the amount.  To substantiate the contention the OP has filed detailed chart.

 

10. Admittedly complainant is not having pre-existing disease.  As per the policy terms and conditions No.5 co-payment which reads here as, “50% for all pre-existing claims and 30% for all other claims”.  The said clause it clearly shows that the complainant is entitled for 30% of co-pay.  Further on perusal of the definition co-payment which reads here as under:

 

Co-payment is a cost-sharing requirement under a health insurance policy that provides that the policy holder/insured will bear a specified percentage of the admissible claim amount.  A co-payment does not reduce the Sum Insured.

 

As per the said definition it clearly shows that policy holder bear a specified percentage of the admissible claim amount and it does not reduce the sum insured.

 

11. Further on perusal of the bill assessment sheet produced by the complainant Ex-A9 the OP authority assessed the admissible amount of Rs.2,26,668/-.As per the terms and conditions the OP has deducted 30% of the co-payment amount from the admissible amount of Rs.2,26,668/- and settle the amount to the complainant. 

 

12. Further the complainant alleged that the OP had admitted only a sum of Rs.2,37,000/- and made unnecessary deduction out of total bill amount of Rs.5,52,444/-.The said allegation of the complainant is vague.  The complainant has not pointed out where the OP has made mistake by deducting the amount.  On the other hand OP submitted that as per the coverage clause-A of the policy,Room,Boarding and nursing expenses are provided by the hospital at 1% of the sum insured subject to a maximum of Rs.6,000/- per day is allowed.  Hence, the OP has totally paid Rs.12,000/-.  As per coverage clause-C  of the policy “surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees subject to a maximum of 25% of the sun insured per hospitalization.  Further as per coverage clause D of the policy, “Anesthesia, blood, Oxygen, Operation Theatre Charges, surgical Appliances, Medicines and Drugs, Diagnostic materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker and similar expenses subject to a maximum of 50% of the sum insured per hospitalization.  Accordingly OP has paid Rs.1,65,900/- by deducting 30% of co-pay.

 

13. On the above discussion made hitherto the OP has acted strictly in accordance with the policy terms and conditions and has rightly rejected the claim of the complaint.  The complainant has failed to prove his case with believable material evidence that there is a deficiency in service on that part of OP.   The oral and documentary evidence of the OP placed before the Forum are more believable and trust worthy and acted upon than the material evidence of the complainant.  As such we are of the opinion that there is no deficiency in service on the part of OP.  Accordingly we answer the point no.1 in negative.

 

14. Point No.2: In the result, for the foregoing reasons, we proceed to pass the following order:    

 

 

O R D E R

 

The complaint filed by the complainant U/s.12 of the Consumer Protection Act, 1986 is dismissed.  Parties to bear their own costs.

 

Supply free copy of this order to both the parties.

 

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Forum on this06^thday of March 2020)

 

 

                                                                        

(SURESH.D)    MEMBER

(ROOPA.N.R)    MEMBER

(PRATHIBHA.R.K)    PRESIDENT

 

Witnesses examined on behalf of the complainant by way of affidavit:

 

Sri.Jayavittal Rao Kolar.

 

 

 

Copies of documents produced on behalf of complainant:

 

 

Ex-A1	Copy ofinsurance policy along with the terms and conditions for the period of 24.03.2015 to 23.03.2016.
Ex-A2	Copy of insurance policy along with the terms and conditions for the period of 24.03.2016 to 23.03.2017.
Ex-A3	Copy of letter dated 27.10.2016.
Ex-A4	Copy of notice dated 16.11.2010 along with postal receipts.
Ex-A5	Copy of the clarification letter dated 21.12.2016 given by Dr.Gopi, the Interventional Cardiologist.
Ex-A6	Copies of letters dated 17.01.2017 and 30.01.2017.
Ex-A7	Copy of letter dated 20.01.2017.
Ex-A8	Copies of legal notice dated 01.03.2017 along with postal receipts, tract record.
Ex-A9	Copy of bill assessment sheet along with payment details.
1)	Copy of authority 1) Hari Om Agarwal v. Oriental Insurance Co. Ltd., 2007 (98) DRJ 254 (DB). 2) Pioneer Urban Infrastructure Ltd. v. Govindan Raghavan, Civil Appeal No.12238 of 2018 (Supreme Court) 3) Gurbax Singh & Ors. V. Star Health and Allied Insurance Co. Ltd., & Ors., Revision Petition No.1795 of 2015 (NCDRC)

 

 

Witnesses examined on behalf of the OP by way of affidavit:

 

 

Pushpavathi, who being working as Legal Officer in OP Company.

 

 

Copies of documents produced on behalf of Opposite Party - Nil

 

 

                                                                        

(SURESH.D)    MEMBER

(ROOPA.N.R)    MEMBER

(PRATHIBHA.R.K)    PRESIDENT