BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 634 of 2019
Date of Institution : 30.10.2019
Date of Decision : 08.09.2023
Parveen Kumar, aged 48 years son of Shri Krishan Kumar, resident of House No.4, IInd Additional Mandi, Sirsa, District Sirsa (Haryana).
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Branch Office: Ground Floor, Opp. Shakti Motors, Near IDBI Bank, Sirsa, Tehsil and District Sirsa, through its Branch Manager.
2. Star Health and Allied Insurance Company Ltd., Regd. Office: 1, New Tank Street, Valluyer Kottam High Road, Nungambakkam, Chennai- 600 034, through its authorized signatory.
…….Opposite Parties.
Complaint under Section 12 of the Consumer Protection Act, 1986.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA……….MEMBER
Present: Sh. JBL Garg, Advocate for the complainant.
Sh. M. K. Saini, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 ( after amendment u/s 35 of C.P. Act, 2019) against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant purchased a Family Health Optima Insurance Plan from the ops vide policy no. P/211119/01/2015/003232 for the period w.e.f. 21.03.2015 to 20.03.2016 and got insured himself, his wife Smt. Isha, daughters Aarju, Nancy and son Jatin Bansal for the basic floater sum insured amount of Rs.5,00,000/- and paid a sum of Rs.13,343/- as insurance premium including CGST/ UTGST for the same. This policy was further got renewed by complainant in subsequent years i.e. 21.3.2016 to 20.3.2017, 21.3.2017 to 20.3.2018 and now from 21.3.2018 to 20.3.2019 and present policy bears number P/211121/01/2018/004149. That in May, 2017 complainant fell ill and he was taken to Sir Ganga Ram Hospital, New Delhi where he was hospitalized and treated and a sum of Rs.2,24,587/- was incurred on his treatment. It is further averred that complainant lodged his claim with the ops and supplied all the required documents and information for settlement of claim but the ops failed to settle and decide the claim of complainant. That earlier also complainant filed a consumer complaint against the ops which was decided on 11.06.2019 and ops were directed to re-open the claim file and thereafter to settle and pay claim of complainant as per terms and conditions of the policy within 45 days of receipt of copy of the order. It is further averred that ops in an illegal, unlawful and arbitrary manner settled the claim of complainant at Rs.1,22,770/- which was inclusive of compensation of Rs.3,000/- and Rs.2,000/- as litigation expenses whereas in fact the complainant was entitled to a sum of Rs.2,24,587/- towards the settlement of his claim and compensation and litigation expenses. In this manner, the ops have paid less amount of Rs.1,06,817/- to the complainant. That complainant has already visited the ops on many occasions and requested for payment of aforesaid amount alongwith interest but the ops continued putting off the matter with one pretext or the other and now two days ago the ops have refused to do so and have caused unnecessary harassment and mental agony to the complainant. Hence, this complaint.
3. On notice, ops appeared and filed written statement raising certain preliminary objections. It is submitted that policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. It is further submitted that insured has submitted claim documents for reimbursement of Rs.1,01,423/- towards the treatment taken from Sir Ganga Ram Hospital, Delhi in May, 2017 and as per order of DCDRF, an amount of Rs.87,860/- was settled to the insured. It is further submitted that complainant/ insured has submitted three claims vide three hospitalization claim Nos. CLI/2018/211121/0099875, CLI/2018/211121/0117889 and CLI/2018/211121/0230466. It is further submitted that with regard to claim no. CLI/2018/211121/0099875, the complainant/ insured was admitted on 25.05.2017 at Sir Ganga Ram Hospital, New Delhi and submitted claim for Rs.1,01,423/- for reimbursement of medical expenses. The answering op had requested insured to provide previous treatment documents but the insured has not furnished the required documents and details even after repeated reminders dated 01.09.2017, 16.09.2017 and 01.10.2017. Thus, having no option, the claim was closed vide letter dated 01.10.2017 and thus the claim was repudiated as per condition no.4 of the policy. With regard to claim no. CLI/2018/211121/0117889, the insured/ complainant was admitted on 06.06.2017 at Sir Ganga Ram Hospital, New Delhi and submitted claim records for reimbursement of medical expenses for Rs.36,410/- and was discharged on the same day. On scrutiny of the claim records, it is observed that the insured has undergone treatment for Hepatitis B, hence they have called for the previous claim document, but the insured has not furnished the required documents and details even after repeated reminders dated 20.10.2017 and 04.11.2017 and thus having no option, the claim was closed vide letter dated 01.10.2017 and claim was repudiated as per condition no.4 of the policy. It is further submitted that with regard to claim no. CLI/2018/211121/0230466, the insured/ complainant submitted pre authorization request on 09.08.2017 towards the treatment at Sir Ganga Ram Hospital and same was denied vide letter dated 09.08.2017 stating that “despite of repeated queries viral load not provided also previous treatment records of Hbsag also not provided, with these available documents cashless cannot be processed” and informed the insured to approach for reimbursement of medical expenses vide letter dated 24.08.2017 and 08.09.2017. It is further submitted that insured has not submitted the required documents, thus the claim was closed vide letter dated 23.09.2017. It is further submitted that aggrieved by the rejection, the insured had approached DCDRF, Sirsa vide CC No. 215/2018 and the Hon’ble Forum vide its order dated 11.06.2019 directed them to settle the claim as per the terms and conditions of the policy with cost of Rs.2000/- and compensation of Rs.3000/- and the same was duly settled by the ops. The answering ops have processed the claim as per the terms and conditions of the policy and the details are as follows:-
A. CLI/2018/211121/0099875:
The claim was approved for Rs.87,860/- against the total bill submitted for Rs.1,06,423/- (Hosp. Exp – Rs. 1,01,943/- + Rs.4480) and deducted Rs.18,563/-.
REASON FOR DEDUCTIONS:
- No X-ray report available. Hence, deducted Rs.1010/-.
- IRDA Guidelines: The charges towards Microshield, Apron Disposables, Mackintosh Draw Sheet, Urobag Aids Kit, Surgeons Gown, Image Intensifier Cover, Ecg Electrodes, Surgical Tape and Disposable Items are not payable. Hence, deducted Rs.3250/-.
- No Details available for Package Charges. Hence, deducted Rs.1330/-.
- The charges towards Hospital MRD (Anaesthesia Charges, Glucometry charges) are not payable. The charges towards Special Equipment Charges are not payable. Hence, deducted Rs.11,813/-.
Pre Hospitalization Expenses
- No Report X-ray available. OPD charges are not payable. Hence, deducted Rs.1160/-.
B. CLI/2018/211121/0117889:
The claim was approved for Rs.34,910/- against the total bill submitted for Rs.36,410/- (Hosp. Exp – Rs.27,760/- + Rs. 8650) and deducted Rs.1500/-.
REASON FOR DEDUCTIONS:
Hospitalization Expenses
- The charges towards ‘Hospital Charges’ are not payable. Hence, deducted Rs.500/-.
Pre Hospitalization Expenses
- In Bill dated 06.06.2019, the patient name is different. Hence, deducted Rs.1000/-.
c. CLI/2018/211121/0230466:
In this claim, the insured had not submitted the claim records towards reimbursement of medical expenses. Hence, we are unable to settle the claim.
Thus, the insured has submitted Rs.106423/- (CLI/2018/211121/0099875) + Rs.36410/- (CLI/2018/211121/0117889), in total, Rs. 1,42,833/- out of which the ops approved an amount of Rs.87,860/- and Rs.34,910/-, in total, Rs. 1,22,770/- which is the maximum amount payable towards the claim.
4.It is further submitted that complainant had not furnished any bills for Rs.2,24,587/- as alleged in the complaint. That answering ops’ is leading health insurance company and providing quality services to its customers as per terms and conditions of the insurance policy. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5.The complainant in evidence has tendered his affidavit Ex.C1 and documents Ex.C2 to Ex.C26.
6.On the other hand, ops have tendered affidavit of Sh. Rajiv Jain, Chief Manager as Ex.R1 and documents Ex.R2 to Ex.R14.
7.We have heard learned counsel for the parties and have gone through the case file carefully.
8.There is no dispute of the fact that complainant purchased the health insurance policy from ops for himself, his wife, two daughters and one son for the sum insured amount of Rs.5,00,000/- for the period 21.03.2015 to 20.03.2016 and the said policy was subsequently got renewed by the complainant for the period 21.03.2016 to 20.03.2017, 21.03.2017 to 20.03.2018 and from 21.03.2018 to 20.03.2019 and in this regard complainant has also placed on file copies of policy schedules as Ex.C3 to Ex.C6. There is also dispute of the fact that in the month of May, 2017 complainant fell ill and was hospitalized and treated in Sir Ganga Ram Hospital, New Delhi up to August, 2017.The complainant has filed the present complaint seeking balance amount of Rs.1,06,817/- from the ops as ops after passing of the order dated 11.06.2019 in the earlier complaint bearing No.215 of 2018 paid the amount of Rs.1,22,770/- to the complainant whereas according to the complainant in fact an amount of Rs.2,24,587/- was spent on his treatment and as such complainant by way of this another complaint is seeking that balance amount of Rs.1,06,817/- from the ops. So only bone of contention between the parties is about differential amount of Rs.1,06,817/- and it is to be decided that whether complainant is entitled to any other remaining amount from ops or not?. According to the ops, only bills to the tune of Rs.1,06,423/- and Rs.36,410/- i.e. for total amount of Rs.1,42,833/- were submitted by the complainant for reimbursement out of which amount of Rs.87,860/- and Rs.34910/- i.e. for total amount of Rs.1,22,770/- were approved and remaining amount was deducted as same was not payable as per terms and conditions of the policy. It is also specific plea of the ops that insured had not submitted bills to the tune of Rs.2,24,587/- as alleged by complainant. However, it is proved on record by complainant that he has spent amount of more than Rs.2,24,587/- on his treatment as is evident from bills/ receipts produced on record by complainant as Ex.C7 to Ex.C14, Ex.C16, Ex.C18 to Ex.C20 and Ex.C22 to Ex.C26. So, it cannot be impossible and believable that complainant / insured who has spent amount more than claimed amount of Rs.2,24,587/- and is having health insurance policy and is renewing the same will not submit the bills to the ops for total amount for reimbursement of the amount. Further more, the ops have not explained that which documents were not submitted by the complainant. It is also pertinent to mention here that in the order dated 11.06.2019 passed in earlier complaint filed by complainant, it has already been held that all the record was already in possession of the ops. Therefore, the ops could only deduct the above said amounts of Rs.18,563,Rs.1500/- and another amount of Rs.1500/- (total Rs.21,563/-) as detailed above by the ops as per terms and conditions of the policy or as per IRDA guidelines since in the order dated 11.06.2019 the ops were directed to re-open the claim file and were directed to pay the claim of complainant as per terms and conditions of the policy, however, in the present case besides deduction of the above said total amount of Rs.21,563/-, the ops have also deducted another huge amount and have only paid an amount of Rs.1,22,770/- to the complainant out of total amount of Rs.2,24,587/- and ops have not justified the deduction of remaining amount. So, in our considered opinion the ops have wrongly and illegally withheld the remaining amount and therefore, complainant is entitled to remaining amount of Rs.85,254/- (after deduction of Rs.21,563/- from Rs.1,06,423/- as claimed by complainant) from the ops.
- In view of our above discussion, we allow the present complaint and direct the opposite parties to pay the remaining claim amount of Rs.85,254/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to interest at the rate of @6% per annum on the said amount of Rs.85,254/- from the date of this order till actual payment. We also direct the ops to further pay a sum of Rs.5,000/- as composite compensation for harassment and litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 08.09.2023. District Consumer Disputes
Redressal Commission, Sirsa.
