IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Dated this the 28th day of January, 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M. Anto, Member
CC No. 285/2021 (Filed on 29/11/2021)
Complainant : Rosh Jacob, aged 54 years, S/o Jacob
Parayil House, Kuzhimattom P.O
Panachikkadu Village, Kottayam Taluk
Kottayam District-686533.
(By Adv.Akash K.R)
Vs
Opposite party : Star Health and Allied Insurance Company
Branch Office, IInd Floor
Puthenpurackal Complex, M.C.Road
Kodimatha, Kottayam-686 013
Represented by its Divisional Manager
(By Adv.Avaneesh V.N)
O R D E R
Sri.Manulal.V.S, President
The complainant filed this complaint Under Section 35 of Consumer Protection Act, 2019.
Crux of the complaint is as follows:
The complainant is the policy holder of a health insurance policy vide renewal endorsement policy no. P/181113/2021/011476 of the opposite party. The opposite party as per letter dated 07-01-2021 renewed the policy from 07-01-2021 to 06-01-2022. The limit of coverage as per the policy is Rs.6,75,000/-. That on 03-07-2021 complainant met with triple vessel coronary artery disease with mild L.V.systolic dysfunction and was hospitalized from 03-07-2021 to 12-07-2021 in Caritas hospital, a network hospital; complainant underwent treatment in the said hospital. The entire treatment expenses of the complainant is Rs.3,40,742/-. Though the complainant duly submitted his claim along with related documents to the opposite party vide intimation no.2831670 dated 03-07-2021, the opposite party had only paid an amount of Rs.2,90,318/- in the hospital. Thus the complainant was forced to pay a sum of Rs.50,419/- to the hospital. The act of the opposite party in not paying the entire hospital expenses of the complainant amounts to deficiency in service and due to the deficient act of the opposite party the complainant was put to much hardship, loss and sufferings for the same opposite party is liable to compensate. Hence this complaint is filed by the complainant praying for an order to direct the opposite party to pay Rs.50,419/- to the complainant along with a compensation of Rs.10,000/- and Rs.5,000/- as cost of this litigation.
Upon notice opposite party appeared before the commission and filed version contenting as follows:
The complainant has taken Family Health insurance policy from the opposite party for the period commencing from 05-09-2012 to 04-09-2013 and the same has been renewed upto 06-01-2022 for a sum insured of Rs.5,00,000/- vide policy number P/181113/2021/011476. The terms and conditions of the policy were explained to the complainant at the time of proposing the policy and the same was served to the complainant along with the policy schedule. After received the cashless request form, the opposite party had initially authorized an amount of Rs.70,000/- and the same was informed to the complainant and the hospital authority on 06-07-2021. The hospital authority had informed the opposite party that the complainant was discharged on 12-07-2021 and after the treatment, the hospital authority had forwarded the discharge summary along with final bill amount of Rs.3,40,742/- and after verifying the claim documents, the opposite party had processed the claim and approved the cashless facility of Rs.2,90,323/- on 12-07-2021. After the discharge from the hospital, the complainant had claimed for pre and post hospitalization expenses of Rs.13,105/- to the opposite party and the opposite party had processed the claim and approved for Rs.10,994/- on 27-08-2021. At the time of reimbursement, the complainant has not submitted the original balance paid receipt of Rs.50,419/- as alleged in the complaint. There is no deficiency in service from the part of the opposite party and the opposite party had acted only as per the terms and conditions of the policy.
Complainant filed proof affidavit and marked exhibits A1 to A3 from the side of the complainant. Padma Prabha who is the legal manager of the opposite party filed proof affidavit and marked exhibits B1 to B8 from the side of the opposite party.
On the evaluation of the complaint, version and evidence on record, we would like to consider the following points.
- Whether there is any deficiency in service or unfair trade practice on the part of the opposite parties?
- 2. If so what are the reliefs and costs?
Point number 1 and 2
There is no dispute on the fact that the complainant has taken Family Health insurance policy from the opposite party for the period commencing from
05-09-2012 to 04-09-2013 and the same has been renewed upto 06-01-2022 vide policy number P/181113/2021/011476. On perusal of exhibit A1 Family Health Optima Insurance Plan it can be seen that the sum insured was Rs.5,00,000/- and the coverage limit was Rs.6,75,000/- including the bonus of Rs.1,75,000/-. Admittedly the complainant had underwent the treatment for triple vessel coronary artery disease with mild L.V. systolic dysfunction and was hospitalized from 03-07-2021 to 12-07-2021 in Caritas hospital. It is proved by discharge bill dated 12-07-2021 which is annexed to the Exhibit B5 discharge summary that the total treatment expense was Rs.3,40,742/-. Admittedly the opposite party has approved and reimbursed an amount of Rs.2,90,318/- out of Rs.3,40,742/-. According to the complainant opposite party committed deficiency in service by rejecting Rs.50,419/- out the total cost of treatment expenses incurred by him.
On going through the exhibit B2 terms and conditions of the policy we can see that the opposite party assured cashless facility for the treatment expenses in the hospital which is enlisted by the insurer as a network hospital. Opposite party contended that the complainant has not submitted the original balance paid receipt of Rs.50,419/- to them for processing the claim. This contention of the opposite party cannot be accepted on the ground that they have processed the claim of the complainant and approved an amount of Rs.2,90,318/- against the total bill of Rs.3,40,742/- as per exhibit B6 cashless authorization letter which is sent by the opposite party to Caritas hospital, which is a network hospital of the opposite party; where complainant underwent treatment. The opposite party has no case that Caritas hospital is not a network hospital of the opposite party.
On perusal of exhibit B6 we can see that the opposite party deducted Rs.3,790/- as sugar and pcr as per the market price and approved only Rs.14,545/- against the claimed amount of Rs.18,335/- and deducted Rs.15,209/- from the claimed amount of Rs.1,06,286/- towards the medicines and consumables. On perusal of exhibit B6 we can see that the opposite party had made a deduction of Rs.26,300/- from an amount of Rs.2,03,000/- stating that angiogram 50% allowed and CABG maximum payable towards package charges and made deduction of Rs.5,120/- towards the head of dietary charges.
Exhibit B8 is the calculation sheet based on which the opposite parties arrived at the admissible amount against the original paid receipt. On perusal of exhibit B8 we can see that opposite party has deducted an amount of Rs.18,800/- from Rs.1,88,000/- which is the amount claimed for the angioplasty expenses. The reason stated in exhibit B8 for the same is that the details are not enclosed. It is further proved by exhibit B8 that the opposite party had deducted Rs.75/- from the amount claimed for Lab charges stating that the same was the charge for the examination of blood group. On perusal of terms and conditions of the policy we cannot see any exclusion clause which entitles the insurer to deduct any amount from the actual amount claimed by the insured for the reason that the details are not enclosed and the expenses for the examination of blood group. Any deduction made which is contrary to the terms and condition of the contract of insurance amounts to the deficiency in service on the part of the opposite party. Moreover in exhibit B8 it is stated that an amount of Rs.24,173/- is payable to the complainant by the opposite party towards the treatment expenses. Thus we are of the opinion that the opposite party is liable to pay Rs.43,048/- (24,173+18,875) to the complainant for the treatment expenses incurred by him. Non payment of the said sum by the opposite party amounts to inadequacy and imperfection in service and deficiency in service. No doubt the deficient act of the opposite party caused much mental agony and hardship to the complainant for which the opposite party is liable to pay compensation. On evaluation of evidence we are of the opinion that the complainant has succeeded to prove his case and the complaint is to be allowed. Hence we allow the complaint and pass the following order.
- We hereby direct the opposite party to pay Rs.43,048/- to the complainant .
- We hereby direct the opposite party to pay Rs.10,000/- as compensation for the deficiency in service on the part of the opposite party.
- We hereby direct the opposite party to pay Rs.2,500/- to the complainant as cost of this litigation.
Order shall be complied within 30 days from the date of receipt of this order in default the award amounts shall carry 9% interest from the date of this order till realization.
Pronounced in the open Commission on this the 28th day of January, 2023.
Sri.Manulal.V.S, President sd/-
Smt.Bindhu.R, Member sd/-
Sri.K.M. Anto, Member sd/-
Appendix
Exhibits marked from the side of complainant
A1- Original copy of the policy certificate dated 07.01.2021.
A2- Copy of the advance receipt dated 12.07.2021.
A3- Copy of the discharge bill dated 12.07.2021.
A4- Copy of the discharge summary dated 12.07.2021.
Exhibits marked from the side of opposite party
B1- Letter dated 07.01.2021 from Star Health and Allied Insurance Co.Ltd
B2- Customer information sheet – Family heath optima insurance plan issued by Star Health and Allied Insurance Co.Ltd.
B3- Request for cashless hospitalization for medical insurance policy issued by Star Health and Allied Insurance Co.Ltd
B4- Cashless authorized letter issued by Star Health and Allied Insurance Co.Ltd
B5- Copy of the discharge summary dated 12/07/2021 issued by Caritas Hospital
B6- Cashless authorization letter dated 12/07/2021 issued by Star Health and Allied Insurance Co.Ltd
B7- Letter dated 28.08.2021 from Star Health and Allied Insurance Co.Ltd
B8- Copy of calculation sheet.
By order
sd/-
Assistant Registrar