Haryana

Kurukshetra

CC/21/2019

Suresh Saini - Complainant(s)

Versus

Star Health Ins - Opp.Party(s)

Chanderjit Saini

01 Feb 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KURUKSHETRA.

 

Consumer Complaint No.21 of 2019

Date of Instt.:17.01.2019

Date of Decision: 01.02.2021.

 

Suresh Saini son of Shri Chamela Ram, resident of house No.1734, Sector 7, Urban Estate, Kurukshetra Tehsil Thanesar, District Kurukshetra.

                                                                        …….Complainant.                                              Versus

 

1.Star Health and Allied Insurance Co. Limited (Claims Department)SCO No.139-131, 4^th Floor, Sector 34-A, Chandigarh through its Manager.

2. Star Health and Allied Insurance Co. Limited through its Branch Manager, SCO No.94, 1^st Floor, back side of Hotel Silver Sand, Sector 17, Kurukshetra, Tehsil Thanesar, District Kurukshetra.

 

 

                ….…Opposite parties.

 

Complaint under Section 12 of Consumer Protection Act.

 

Before       Smt. Neelam Kashyap, President.    

                   Ms. Neelam, Member.       

                   Shri Issam Singh Sagwal, Member.                

                 

Present:     Shri Chanderjit Saini Advocate for the complainant.         

Shri  Gaurav Gupta  Advocate for the opposite parties.

ORDER

                  

                 This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by the complainant Suresh Saini against Star Health and Allied Insurance Co. etc, the opposite parties.

 

2.             The brief facts of the complaint are that the complainant purchased policy Star Comprehensive Insurance bearing No.P/211123/01/2018, from May 2017 to 30.4.2018 for the sum assured of Rs.5.00 lac. The respondents received the full and final premium of Rs.27,186/-. It is further averred that on 26.12.2017, the complainant fell ill  (High Grade Fever Associated with Rigors and Chills) and was admitted to Fortis Hospital, Sector 62, Phase-III, Mohali and was discharged on 1.1.2018. The  complainant has spent huge amount on his treatment. The complainant submitted the bills and receipts etc.of Rs.1,50,869/- to the OPs immediately without any delay  as demanded by the OPs.  The complainant claimed for reimbursement of the said amount from the OPs vide claim intimation No.OLI/20178/211123/0514026.  On 5.3.2018, OPs paid a part claim of Rs.74,815/- out of the total amount spent by the complainant. The complainant requested the OPs to make the full payment on which the OPs advised the complainant to  submit  affidavit regarding loss of original receipt No.902 dated 30.12.2017 for Rs.50,000/- and in compliance of their direction, the complainant submitted affidavit dated 10.4.2018 duly attested to OP No.2 regarding loss of said receipt but inspite of that the OPs have not re-imbursed  the remaining amount. Moreover, the OPs illegally deducted Rs.5700/-  as expenses of investigation. Thereafter OPs issued letter dated 10.07.2018 to the complainant alleging that duplicate receipt submitted for Rs.50,000/- as per guidelines affidavit is not  acceptable which is illegal and void. The complainant also got served legal notice dated 20.7.2018 upon the upon the OPs but the OPs replied the said legal notice falsely and did not pay the remaining amount. Thus, the complainant has filed the present complaint alleging deficiency in services on the part of the OPs and prayed for  payment of Rs.76,054/-  alongwith interest, compensation for damages and litigation expenses.

 

3.             Upon notice OPs appeared and filed their written statement disputing the claim of the complainant. Obtaining of Insurance policy for the sum assured Rs.5.00 lacs has been admitted by the OPs.  It is also admitted that the insured patient got hospitalized on 26.12.2017   in Fortis Hospital Mohali and the hospital has raised a pre-authorization request for availing cashless facility for the treatment of   Pyrexia Abscess in Left Stern Cledo Mastoid and the same was reviewed and observed that as per provided case papers, patient is diagnosed  with UTI/Diabetes Mellitus/Cervical spondylosis and disc bulge falls under first two years exclusion. Moreover, part payment for urinary tract infection is not possible in cashless. Hence the cash authorization was denied and the same was communicated to the insured vide letter dated 29.12.2017. However, answering OPs has also advised the insured to come for reimbursement with all required documents to evaluate the claim vide letter dated 4.1.2018.  Subsequently, the insured submitted a claim and the claim was processed and amount o f Rs.74815/- was paid as per terms and conditions of the policy.  The complainant had claimed the amount of Rs.1,50,869/- and deduction of Rs.78,054/- was made and after adding cyash benefit amount of Rs.75815/- was paid to the complainant.  The insured submitted a representation dated 21,6,2018 alongwith the affidavit for the duplicate receipt of Rs.50,000/-  and the same was reviewed and observed that as per their  guide lines affidavit is not acceptable and the same was communicated  to the insured vide letter dated 11.07.2018. Thus, it is submitted that there is no deficiency in services on the part of the OPs and prayed for dismissal of the present complaint.

 

4.             The  complainant in support of his case  has filed affidavit Ex.CW1/A and tendered documents Ex.C-1 to Ex.C18 and closed his evidence.

 

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

 

6.             The learned counsel for the complainant  while reiterating the averments made in the complaint has argued that the OPs paid less amount of Rs.76054/- to the complainant and he is entitled for the same. It is further argued that the OPs  have wrongly not considered the receipt and affidavit submitted by him regarding the amount of Rs.50,000/-, therefore, he is entitled to the said amount alongwith the litigation expenses.

 

7.             On the other hand learned counsel for the OPs while reiterating the  submissions made in the written statement has argued that as per the guide lines of the policy issued to the complainant, they have rightly paid the sum of Rs.74815/- to the complainant and now nothing is payable to him. He has further argued that  duplicate receipt and affidavit submitted by the complainant were not acceptable and there is no deficiency in services on the part of the OPs and prayed for dismissal of the present complaint.

 

8.             After hearing the learned counsel for the parties, we are of the view that deductions made by the OPs as envisaged in preliminary objection no.2 of their reply are just and proper. However, the OPs have wrongly not considered the duplicate receipt and affidavit submitted for Rs.50,000/- by the complainant.  The complainant  submitted the affidavit Ex.C-13 in this regard stating therein that he has lost the receipt No.902 dated 50,000/- issued from Fortis Hospital.  He has also submitted the duplicate receipt with the claim No.9314026.  The receipt No. 902 dated 30.12.2017 is not self made by the complainant  rather it was issued by Fortis Hospital, Mohali for the treatment of the  complainant and receipt of the said amount of Rs.50,000/-. The OPs could have verify the issuance of the receipt from Fortis Hospital, Mohali and fact regarding payment thereof.  Every insurance companies have their own investigating agencies and the investigation regarding the receipt of Rs.50,000/- has not been made by the OPs. Thus, withholding the payment of Rs.50,000/- by the OPs is illegal and void and not sustainable in the eyes of law and as such deficiency in services on the part of the OPs is made out.  Therefore, the complainant is found entitled for the sum of Rs.50,000/-  paid by him in view of receipt No.902 dated 30.12.2017.

 

9.             In view of our aforesaid discussion and observations, the present complaint is hereby accepted and the OPs are directed to make the payment of Rs.50,000/- to the complainant.  The complainant shall also be entitled for compensation the sum of Rs.5000/- for the mental harassment and agony caused to him. The OP are    further directed to make the compliance of this order within a  period of 45 days from the  the date of preparation of certified copy of this order, failing which, the complainant will be at liberty to initiate proceedings under Section 25/27 of the Act against the OPs. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

 

Announced in open Forum:

Dt.:01.02.2021                                                                                                                                                                                                                                                                    (Neelam Kashyap)

                                                                             President.

 

 

(Issam Singh Sagwal),         (Neelam)       

 Member                              Member.