Karnataka

Kolar

CC/26/2018

Sri.Prakash - Complainant(s)

Versus

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

Sri.B.Safasivachari

10 Jan 2019

ORDER

Date of Filing: 31/03/2018

Date of Order: 10/01/2019

BEFORE THE KOLAR DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, D.C. OFFICE PREMISES, KOLAR.

 

Dated: 10^th DAY OF JANUARY 2019

PRESENT

SRI. K.N. LAKSHMINARAYANA, B.Sc., LLB., PRESIDENT

SMT. A.C. LALITHA, BAL, LLB.,  ……  LADY MEMBER

 

CONSUMER COMPLAINT NO. 26 OF 2018

Sri. Prakash,

S/o. K.K. Babu Rao,

Aged About 46 Years,

Near Shankar Eye Clinic,

Aralepet, Kolar.                                                              ….  COMPLAINANT.

(Rep. by Sri. B. Sadasivachari, Advocate)

 

- V/s -

1) Star Health & Allied Insurance

Company Limited, 1^st Floor,

New Kolar Nursing Home Building,

Antaragange Road, Kolar.

 

2) Star Health & Allied Insurance

Company Limited, No.1, New Tank

Street, Valluvar Kottam High Road,

Nungambakkam, Chennai-600 034.

(OP Nos.1 & 2 are Rep. by

Sri. G.R. Ramachandra Murthy, Advocate)                …. OPPOSITE PARTIES.

-: ORDER:-

BY SRI. K.N. LAKSHMINARAYANA,PRESIDENT

01.   The complainant has filed this complaint against the opposite parties and prays to direct the OP Nos.1 & 2 to pay the final insured bill amount of Rs.6,18,876/- with compensation of Rs.2,00,000/- towards mental agony, loss of precious time and money along with interest at the rate of 2% per month till its realization in the ends of justice and equity.

 

02.   The brief facts of the complainant’s case is that, the complainant is the customer of OP Nos.1 & 2 vide customer ID No.2474420-2 and is the policy holder under Family Health Optima Insurance Plan bearing No. P/141119/01/2017/000757, Customer Code AA0000446852, dated: 16.08.2016.  The policy is in force from 18.08.2016 to midnight of 17.08.2017 and the scheme description is for 02 Adults + 2 children basic floater sum insured is Rs.3,00,000/-.  The complainant proposed the policy on 18.08.2012 i.e., the date of inception of first policy and now the same was in force as fourth renewal year.  The policy limit of coverage is Rs.4,50,000/-.  On 24.06.2017 he was admitted to Manipal Hospital, HAL Airport Road, Bangalore, as inpatient vide No.10000337563 (Department of Spine Care) with a chief complaint of Back Pain and urinary disquisition and discharged on 28.06.2017.  The complainant undergone surgery on 24.06.2017 i.e., posterior decompression and instrumented posterolateral fusion L1-L5 posterior lumbar interbody body fusion L4-L5 and thoracic laminectomy D-10-D11 which was performed by Dr. Vidyadhara S (Ulrich titanium implants) with further advise on discharge to review with Dr. Vidyadhara S at Spine Care OPD for drain removal on 04.07.2017 with prior appointment.  The suture removed at local hospital / Spine Care OPD after 2 weeks.  On 28.06.2017 at the time of discharge the complainant paid final bill of Rs.6,18,876/-.  Earlier at the time of admission after contacting OP Nos.1 & 2 they sent Rs.1,50,000/- and suddenly on 28.06.2017 the OPs have withdrawn the same by way of authorization letter as the claim is denied which is unknown to the complainant.  The complainant with great difficulty had paid the initial and final bill to the hospital.  Though the policy was in force at the time of taking treatment as inpatient the OPs have not provided service and the complainant become very depressive and suffered mental agony.  The complainant’s relatives and friends supported him financially to bear the medical bills.  The denial of the service by the OPs amounts to deficiency in service and further they have cheated the complainant for wrongful gain by way of illegal means.  The complainant has issued legal notice to both the OPs, but the OPs have neither cared to reply nor paid the amount even after submission of claim form.  Due to the negligence act and deficiency in service on the part of the OP Nos.1 & 2.  The complainant had suffered lot of mental agony and inconvenience.  Hence the complaint.

 

03.   The OP appeared through the counsel and filed its version and contended that, the complaint is not maintainable either in law or on facts and the complainant has not approached this Forum with clean hands.  The complainant without complying with the request made by OPs has approached this Forum only with a view to harm and harass the OPs.  The allegations made in para-1 to 3 in the complaint may be true and correct.  The allegations in para-4 that, the complainant was admitted to Manipal Hospital, Bangalore, and was discharged may be true and correct and the rest of the allegations made therein is not within the knowledge of these OPs.  The allegations in para-5 of the complaint that, the OPs have given authorization letter and later withdrawn the amount is true and correct.  The reason being a query have been raised vide letter dated: 28.06.2017 for treating details in respect of ailment and insured was called upon to approach the OPs for reimbursement, but the complainant has failed to produce original final bill with payment receipt and invoice for implant and the OPs have reminded the complainant through letters dated: 14.12.2017, 29.12.2017 to furnish the above said documents which are mandatory to process the claim.  Without complying the request of OPs the complainant has approached this Forum.  At the time of entering to policy the insurance has accepted the terms and conditions of the company.  As per condition No.4 of the policy “the insured person shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance of the company may require in dealing with the claim”.  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 that “the insurance under this policy is subject to conditions, clauses, warranties, exclusions, etc., attached”.  The policy issued to the complainant is governed by limits of liability as per various clauses.  On receipt of original final bill with payment receipt and invoice for implant the claim will be processed as per the terms and conditions of the policy and prays to dismiss the complaint in the interest of justice and equity.

 

04.   The complainant has filed affidavit evidence by way of examination-in-chief and produced Annexure-A to Annexure-H documents.  The OP did not adduce any evidence on their side. The OP has filed a Memo dated: 04.07.2018 with copy of the calculation sheet.

 

05.   Heard arguments on complainant side.

06.   Now the points that do arise for consideration are:-

(1)    Whether the complainant has proved deficiency in service on the part of the OPs?

 

(2) Whether the complainant is entitled for the reliefs as prayed by him?

 

(3) What order?

 

07.   Our findings on the above stated points are:-

POINT (1):-      In the Affirmative

POINT (2):-      Partly in the Affirmative

POINT (3):-      As per the final order

for the following:-

REASONS

POINTS (1) & (2):-

08.   These points are taken up together for discussion to avoid repetition of facts and reasonings.  Perused the complaint, version, affidavit evidence of complainant along with documents produced by both the parties.  The counsel for the complainant addressed arguments that, non-payment of medical claim under the health insurance policy amounts to deficiency in service on the part of the OPs and prays to allow the complaint.  The counsel for the OPs has addressed that the complainant himself has not complied to the request of the OPs and there is no negligence and deficiency of service on the part of the Ops and prays for dismissal of the complaint in the interest of justice and equity.

 

09.   On perusal of the pleadings there is no dispute that, the complainant has taken a Family Health Optima Insurance Plan Policy bearing No.P/141119/01/2017/000757, Customer Code AA0000446852, dated: 16.08.2016, from the OPs and the complainant admitted to Manipal Hospital, HAL Airport Road, Bangalore, on 24.06.2017 as inpatient and he was discharged on 28.06.2017.  The complainant has produced Annexure-A to Annexure-H as follows:-

Insurance Policy – Annexure-A, Copy of Customer ID – Annexure-B, Copy of inpatient interim running bill – Annexure-C, Copy of withdrawal of authorization letter –Annexure-D, Copy of inpatient final bill cum receipt – Annexure-E, Copy of Discharge summery – Annexure-F, Legal Notice dated: 03.07.2017 – Annexure-G, postal acknowledgment – Annexure-H

 

On perusal of Annexure-A the said policy was with effect from 18.08.2016 to midnight of 17.08.2017 and the date of proposal was on 18.08.2012 and the said policy is in force as on the date of the admission of the complainant to the Hospital.  The complainant has not produced original discharge summary and so also the final bill.  On perusal of Annexure-E i.e., copy of the inpatient final bill it reveals total amount of Rs.6,18,876/-.  The complainant has also failed to produce the documents before the OPs in spite of reminder letters dated: 14.12.2017 and 29.12.2017.

 

10.   On 07.06.2018 the complainant has filed version and the matter was posted for complainant’s evidence by 14.06.2018 and on that day both parties and the counsels submitted that, the matter is likely to be settled and thereafter the matter was dragged-on, though the OPs have agreed for issue of cheque in favour of the complainant in respect of the amount as per the letter of the counsel for OPs dated: 04.07.2018 i.e., a sum of Rs.3,00,000/-, but the OP declined in settling the claim and so also they withdrawn the amount of Rs.1,50,000/- by denying the claim while complainant taking treatment and the OPs failed and neglected in rendering service to the complainant and made the complainant to suffer much more at the time of taking treatment.  The complainant opted such health insurance policy to avail medical facility whenever they require, but the OPs failed to render their service which amounts to deficiency of service.

 

11.   The OP did not adduce any evidence on their side.  On 03.01.2019 the counsel for complainant has filed Memo stating that, the complainant has given consent for settling the matter for Rs.3,00,000/- and prays to direct the OP No.1 to pay the said amount with compensation.  In that view of the matter it is not just and necessary to go through further detail in the matter as the complainant has agreed to receive the said amount of Rs.3,00,000/- as per the letter of the OP dated: 04.07.2018 along with compensation.  The OP along with the said letter has also produced copy of calculation sheet for payment of total amount of Rs.3,00,000/-.

 

12.   The complainant has agreed for the said amount and he is entitle for Rs.3,00,000/- towards medical expenses and so also compensation of Rs.10,000/- and litigation expenses of Rs.2,000/- as full and final settlement of his claim subject to production of original discharge summary and final bill before OP only to avoid double payment if any.  Both OPs are jointly and severally liable to pay the said amount to the complainant.  Hence as discussed above, we answer Point (1) in the Affirmative and point (2) in the partly affirmative. 

 

POINT (3):-

13.   In view of the above discussions on Points (1) & (2) we proceed to pass the following:-

ORDER

01.   The complaint filed by the complainant is allowed-in-part.

 

02.   The OPs are directed to pay a sum of Rs.3,00,000/- towards health insurance claim of the complainant along with compensation of Rs.10,000/- and litigation expenses of Rs.2,000/-to the complainant within 30 days from the date of communication of this order.  Failing which, the OPs shall pay interest at the rate of 9% per annum from the date of filing of complaint till payment of the said amount.

 

03.   Send a copy of this order to both parties free of cost.

(Dictated to the Stenographer, transcribed by him, corrected and then pronounced by us on this 10^th DAY OF JANUARY 2019)

 

 

 

LADY MEMBER                                PRESIDENT