BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 704 of 2019
Date of Institution : 10.12.2019
Date of Decision : 13.06.2023
Vishal Arora aged about 38 years son of Shri Ram Kishan Arora, resident of Near Vikas High School, Aggarsain Colony, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Ground Floor, Rathore Tower, Dabwali Road, Near Hotel Mehak, Opp. Shakti Motors, Sirsa through its Branch Manager/ Authorized Signatory.
2. Star Health and Allied Insurance Company Ltd., office at SCO 130-131, 4th Floor, Sector 34A Chandigarh through its AGM/ Authorized Signatory.
3. Star Health and Allied Insurance Company Ltd., Grievance Department No.1, New Tank Street, Valluvar Kottam High Road, Vungam Bakkam, Chennai- 600034, through its Managing Director.
…….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. Preet Amar, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
In brief, the case of complainant is that on 25.10.2018 complainant had purchased health care insurance policy namely Family Health Optima Insurance Plan bearing No. P/211121/01/2018/001530 from op no.1. The said policy was valid for a period of one year w.e.f. 25.10.2018 to 24.10.2019 and complainant paid premium amount of Rs.13,057/- to the ops and total sum assured amount was Rs.5,00,000/-. The limit of coverage was Rs.6,75,000/- with recharge benefit of Rs.1,50,000/-. It is further averred that unfortunately after the purchase of policy, complainant felt problem in breathing and he immediately got himself medically checked from Sir Gangaram Hospital, Delhi and he was advised operation for the same. That complainant told the hospital authorities about the health policy and as such hospital authorities through request for cashless hospitalization made the ops aware about estimated cost of the treatment to be Rs.1,15,250/- which was accepted by ops and a sum of Rs.50,000/- was deposited by ops on 11.10.2019 with the hospital and remaining amount was agreed to be paid after the treatment. It is further averred that as such complainant got himself operated and treated from the said hospital and remained admitted from 12.10.2019 to 15.10.2019. That on amount of Rs.1,88,938/- has been incurred by complainant including hospitalization, various tests, medicines and life saving drugs etc. The complainant lodged his claim dated 11.10.2019 with the ops and requested ops to indemnify his claim as per terms and conditions of policy and a further sum of Rs.28931/- was deposited by ops with the hospital authorities but remaining insured amount was declined without any explanation and rest of the amount is still to be paid by ops. It is further averred that on demand of ops, the requisite documents were got submitted by complainant with the ops but ops declined to pay the rest of amount on 21.10.2019, however, at the time of issuing the policy, no terms and conditions have been disclosed to the complainant. That such act and conduct of the ops amounts to deficiency in service and unfair trade practice and they have caused unnecessary harassment and mental agony to the complainant. Hence, this complaint.
2. On notice, ops appeared and filed written version raising certain preliminary objections. The issuance of policy in question, treatment of complainant and payment of Rs.78,931/- is admitted. However, it is submitted inter-alia that the reasons for deduction are as follows:-
Hospitalization expenses:
As per the Exclusion No.24 of the policy, Septal framework surgery not payable. Hence charges related to the same deducted. Hence, a sum of Rs.33,978/- was deducted from OT charges. Further, a sum of Rs.63,102/- was deducted from Professional Fees (Surgeon, Anesthetist, Consultation charges etc.
As per other excluded expenses of the policy, bandage, tegadrem, gypsona, sheet, micro-shield, id band, ecg electrodes, tape, disposable charges Septal framework surgery not payable. Hence charges related to the same deducted. A sum of Rs.12,227/- was deducted from Medicines – outside Hospital.
As per other Excluded expenses of the policy, dressing charges are not allowed. Hence, the sum of Rs. 200/- was deducted from Procedure charges. MRD charges are also not payable. Hence, a sum of Rs.500/- was deducted from others.
3. It is further submitted that claim was processed as per terms and conditions of the policy. The total claimed amount was Rs.1,88,938/-, deductions of Rs.1,10,007/- were made and total amount of Rs.78,931/- which is maximum amount payable as per terms and conditions of policy was paid to the hospital and the insured vide NEFT on 02.11.2019. It is further submitted that as per exclusion no.24, the company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of : All types of Cosmetic, Aesthetic treatment of any description, all treatment of erectile dysfunctions, change of Sex. That Septal framework surgery falls under the Aesthetic treatment, hence the same was not considered as per terms and conditions of the policy. Remaining contents of contents are also denied to be wrong and prayer for dismissal of complaint made.
4. The complainant in evidence has tendered his affidavit Ex. CW1/A and copies of documents i.e. policy schedule Ex.C1, nominee details Ex.C2, request for cashless hospitalization Ex.C3, estimate/ details of patient admitted Ex.C5, cashless authorization letter Ex.C6, details of deductions Ex.C7, hospital bill Ex.C8, discharge summary Ex.C9, application for remaining claim amount Ex.C10, email of op regarding refusal of remaining claim Ex.C11 and certificate of Dr. Manish Munjal of Sir Ganga Ram Hospital Ex.C12.
5. On the other hand, ops have tendered affidavit of Sh. Rajiv Jain, Chief Manager as Ex.R1 and copies of documents i.e. proposal form Ex.R2, cashless authorization letter dated 11.10.2019 Ex.R3, cashless authorization letter dated 15.10.2019 Ex.R4, letter regarding approval of the amount of Rs.78,931/- as Ex.R5, rejection letters regarding request for enhancement of amount for cashless treatment dated 15.10.2019 Ex.R6 and Ex.R7 and discharge summary Ex. R8.
6. We have heard learned counsel for the parties and have gone through the case file carefully.
7. It is proved on record that complainant availed Family Health Optima Insurance Plan from the ops for sum insured amount of Rs.5,00,000/- for the period 25.10.2018 to 24.10.2019 and in the said plan, complainant Vishal Arora, his wife Deepika and daughter Aarzoo were insured as is evident from policy schedule Ex.C1. The complainant paid premium amount of Rs.13,057/- to the ops. During the period of said policy, as complainant felt problem in breathing due to nasal obstruction, the complainant was admitted in Sri Ganga Ram Hospital, Delhi on 12.10.2019 and as per discharge summary Ex.C9 he was diagnosed “LEFT SIDED DEVIATED NASAL SEPTUM WITH SPUR WITH ITH” as complainant was having nasal obstruction since three months before 12.10.2019. On 12.10.2019 itself complainant was operated for Septal framework correction i.e. nose surgery and he was discharged on 15.10.2019 as is evident from discharge summary Ex.C9. It is also proved on record that before the said surgery, estimate of Rs.1,15,250/- was given by Sir Ganga Ram Hospital, New Delhi to the complainant as expected cost of hospitalization which was also approved by the ops and same is not disputed by the ops. So, it is proved on record that said amount of Rs.1,15,250/- was only expected cost of hospitalization as mentioned in document Ex.C5 whereas total bill of Rs.1,88,938/- was prepared by the above said hospital on account of Room Rent & Nursing charges, OT charges, Surgeon Anesthetist, Consultation charges, medicines and consumables etc. as is evident from Ex.C7 and bill of the hospital Ex.C8. The ops only paid amount of Rs.78,931/- to the hospital and amount of Rs.1,10,007/- has been deducted by the ops on above said exclusion clause no.24 and on account of other excluded expenses on the ground that Septal framework surgery falls under the Aesthetic treatment. The Aesthetic treatment is surgery of the face and nose to increase the beauty and to look handsome whereas in the present case the complainant was operated for nasal obstruction as he was having problem of breathing. The surgery of the nose of the complainant has been done as nasal septum of the nose of complainant was displaced to one side and as such complainant was feeling problem in breathing and surgery has only been done to straight the deviated septum i.e. to give proper shape to the nose so that complainant can take proper breathing and it cannot be said that complainant got Aesthetic treatment. The above said treatment of complainant was only started after approval from ops. So, the ops have wrongly and illegally deducted the above said amounts on the said exclusion clauses. Moreover, it is not proved on record by cogent and convincing evidence that ever terms and conditions of the policy were sent to the complainant alongwith policy schedule. The amount of Rs.1,15,250/- was increased to Rs.1,88,938/- by the hospital due to various tests and costly drugs and life saving drugs given to the complainant and as the sum insured amount of the policy is Rs.5,00,000/-, therefore, complainant is entitled to the remaining amount of Rs.1,10,007/- which was paid by complainant to the hospital as ops only paid amount of Rs.78,931/- to the hospital.
8. In view of our above discussion, we allow the present complaint and direct the opposite parties to pay the remaining claim amount of Rs.1,10,007/- 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 receive the above said amount of Rs.1,10,007/- alongwith interest @6% per annum from the date of this order till actual realization from the ops. We also direct the ops to further pay a sum of Rs.10,000/- 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: 13.06.2023. District Consumer Disputes
Redressal Commission, Sirsa.
JK
