Haryana

Kurukshetra

CC/440/2020

Amit Gupta S/o Subhash Chand Gupta - Complainant(s)

Versus

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

In Person

24 Nov 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KURUKSHETRA.

 

           Complaint No.440 of 2020

Date of Instt.:21.12.2020

Date of Decision: 24.11.2021.

 

Amit Gupta Advocate son ofSh.Subhash Chand Gupta resident of House No.113/5, near Jawala Ji Mata Mandir, Red Road, Ladwa, District Kurukshetra.

 

                                                                        …….Complainant.                                              Versus

 

Star Health and Allied  Insurance Company Limited through its Branch office, 2^nd Floor,S.C.F.-137, near ICICI Bank, Sector 13, Karnal 132001 through its Branch Manager.

                ….…Opposite party.

 

                Complaint under Section  35 of Consumer Protection Act.

 

Before       Smt. Neelam Kashyap, President.    

                   Shri Issam Singh Sagwal, Member.

                   Ms.Neelam Member.

                 

Present:     Complainant in person.

                 Sh.Mohit Goyal Advocate for the OP.

.

ORDER

                  

                 This is a complaint under Section 35  of the Consumer Protection Act, 1986 moved by Amit Gupta.   against Star Health Insurance Co. -the opposite party.

2.                The brief facts of the complaint  are that the complainant got the insurance policy No.P/211114/2021/001285  from the OP for the period 16.5.2020 to 15.5.2020.  The said policy was purchased by him through its agent Babli Devi and at the time of purchase of the policy, they assured that the policy is cashless and in case of any health problem accrued to him due any of the illness, then the OP will pay all the medical expenses and other amount to the hospital on penal and the complainant has no liability to pay a single penny to the hospital and in case  the hospital is not on the panel of OP, then the OP would pay the expenses to the complainant within a week. It is further stated that on 12.8.2020 the complainant was admitted in the Fortis Hospital Limited, B-22, Sector -62, Noida 201301 due to health problem and the said hospital treated the complainant and the complainant was discharged on 23.8.2020 and deposited Rs.20,000/-  at the time of admission with the hospital vide receipt No.1104/DP/2008/132171 dated 12.08.2020 . However, discount of Rs.20985/- was given by the hospital due to his relation from the hospital on the bill amount of Rs.2,06,742/-. The complainant deposited all the documents and receipt with the OP and he also incurred Rs.50,000/- as medicine and care of the transportation at the time of said bill, he also sub mitted such papers. On submission of papers, authorized person of OP visited the hospital and they have reported the medical problem that covers under the policy. The OP did not pay the fully amount and paid only Rs.1,65,757/- to the complainant which is deficiency in services on the part of the OP and the complainant is entitled to the balance amount of Rs.90,985/- .Thus, the complainant has filed the present complaint alleging deficiency in services on the part of the OP and prayed that the OP be directed to pay the balance amount of Rs.90,985/- alongwith compensation for the mental harassment caused to him and the litigation expenses.

3.                OP appeared and filed written statement disputing the claim of the complainant. It is submitted that the claim was reported on the said policy and was registered as claim No.CLI/2021/211114/-231593 in regard to hospitalization of the insured patient Amit Gupta at Fortis Hospital Limited, Noida with treatment of COVID Positive, Pneumonia. The insured patient Amit Gupta was hospitalized at Fortis Hospital  from 12.08.2020 to 23.08.2020.The insured requested for cashless authorization based upon the submitted cashless documents, the claim was processed and an amount of Rs.1,65,757/- was approved and paid to hospital through NEFT – 009041511892 on 4.09.2020. It is further submitted that the insured submitted the claim for reimbursement  to reconsideration the amount of Rs.44085/- .The claim was again reviewed and considered for settlement for an amount ofRs.3,100/- and it was paid to the insured through cheque No.734894 dated 22.10.2020. The  some amount was deducted as demanded by the insured. As per excluded expenses no.72, the expenses of irrelevant to the present diagnosis is not payable. Hence, an amount of Rs.8514/-  was deducted. Like wise  charges towards fix (No.181) disposable kit (No.180) , apron ( No.92) electrodes ( No.162) paste ( No.39) sanitizer googles ( No.60), Razor are not payable. Hence amount of Rs.23,774/- was deducted.  As  per the other excluded   expenses, the charges towards Cannulation and other are not payable, hence an amount ofRs.23774/- was deducted and total deduction was of Rs.40,985/-. Thus, it is submitted that there is no deficiency in services on the part of the OP and prayed for dismissal of the present complaint.

4.                The complainant in support of his case has filed his affidavit Ex.CW1/A and closed his evidence after tendering the documents Ex.C-1 and Ex.C-2.

5.                On the other hand, the OP in support of its case has filed affidavit Ex. RW1/A and tendered documents Ex.R-1 to Ex.R-15 and closed its evidence.

6.                We have heard the learned counsel for the parties and gone through the material available on the case file.

7.                The learned counsel for the complainant while reiterating the averments made in the complaint has argued that complainant got the insurance policy No.P/211114/2021/001285 Ex.C-1  from the OP for the period 16.5.2020 to 15.5.2020.  The said policy was purchased by him through its agent Babli Devi and at the time of purchase of the policy, they assured that the policy is cashless and in case of any health problem accrued to him due any of the illness, then the OP will pay all the medical expenses and other amount to the hospital on penal and the complainant has no liability to pay a single penny to the hospital and in case  the hospital is not on the panel of OP, then the OP would pay the expenses to the complainant within a week. It is further stated that on 12.8.2020 the complainant was admitted in the Fortis Hospital Limited, B-22, Sector -62, Noida 201301 due to health problem and the said hospital treated the complainant and the complainant was discharged on 23.8.2020 and deposited Rs.20,000/-  at the time of admission with the hospital vide receipt No.1104/DP/2008/132171 dated 12.08.2020.However, discount of Rs.20985/- was given by the hospital due to his relation from the hospital on the bill amount of Rs.2,06,742/-. The complainant deposited all the documents and receipt with the OP and he also incurred Rs.50,000/- as medicine and care of the transportation at the time of said bill, he also sub mitted such papers. On submission of papers, authorized person of OP visited the hospital and they have reported the medical problem that covers under the policy. The OP did not pay the fully amount and paid only Rs.1,65,757/- to the complainant which is deficiency in services on the part of the OP and the complainant is entitled to the balance amount of Rs.90,985/- .Thus, the complainant has filed the present complaint alleging deficiency in services on the part of the OP.

8.                On the other hand, the learned counsel for the OP has argued that claim was reported on the said policy and was registered as claim No.CLI/2021/211114/-231593 in regard to hospitalization of the insured patient Amit Gupta at Fortis Hospital Limited, Noida with treatment of COVID Positive, Pneumonia. The insured patient Amit Gupta was hospitalized at Fortis Hospital  from 12.08.2020 to 23.08.2020.The insured requested for cashless authorization based upon the submitted cashless documents, the claim was processed and an amount of Rs.1,65,757/- was approved and paid to hospital through NEFT – 009041511892 on 4.09.2020. It is further submitted that the insured submitted the claim for reimbursement  to reconsideration the amount of Rs.44085/- .The claim was again reviewed and considered for settlement for an amount ofRs.3,100/- and it was paid to the insured through cheque No.734894 dated 22.10.2020. The  some amount was deducted as demanded by the insured. It is further argued that as  per excluded expenses no.72, the expenses of irrelevant to the present diagnosis is not payable. Hence, an amount of Rs.8514/-  was deducted. Like wise  charges towards fix (No.181) disposable kit (No.180) , apron ( No.92) electrodes ( No.162) paste ( No.39) sanitizer googles ( No.60), Razor are not payable. Hence amount of Rs.23,774/- was deducted.  As  per the other excluded   expenses, the charges towards Cannulation and other are not payable, hence an amount ofRs.23774/- was deducted and total deduction was of Rs.40,985/-.

9.                In this case, obtaining of the insurance policy, ailment and treatment of the complainant, submission of bill of Rs.2,06742/- and payment of Rs.16557/- by the OP to the hospital are not in dispute. It is also not in dispute that the Ops have made the deduction ofRs.40985/- from the bill amount of Rs.2,06,742/- As per the complainant balance amount of Rs.90985/- has not been paid to him but he has not led any cogent evidence to show that the balance amount of Rs.90985/- remained after payment of Rs.1,65,757/-   We are of the view that being the cashless policy, the Ops were supposed to pay the entire treatment expenses to the hospital but the OP has made deduction of Rs.40985/- and has submitted that  deduction ofRs.40985/- has been made as  shown in Ex.R-10 and the complainant is bound by the terms and conditions and schedule of the policy. In our view until or unless any specific term or condition or schedule is not got noted from the insured, the same is not binding upon him. The Ops have  failed to show that the said terms or conditions or policy schedule has been supplied and got noted from the complainant. Therefore, the complainant is entitled for refund of Rs.40985/- as wrongly deduced by the OP and as such there was deficiency in services on the part of the OP.

8.             In view of our above discussion, we accept the present complaint and direct the OP make the payment of Rs.40985/- to the complainant within a period of thirty days from the date of this order, failing which the complainant shall be entitled to interest on the said amount @ 6% per annum from the date of filing of the present complaint i.e. 21.12.2020 till its actual realization.   The OP is further directed to make the  compliance of this order, failing which the complainant shall be at liberty to initiate proceedings u/s 71 of the Consumer Protection Act. A copy of this order be supplied to the parties free of costs and the file be consigned to the record room after due compliance.

 

 

Announced in the Open Commission

Dated: 24.11.2021.           

       

                                                                               President.

 

                                      Member          Member