Complaint filed on: 27-07-2022

                                                      Disposed on: 21-08-2023

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, TUMAKURU

          DATED THIS THE DAY 21^st DAY OF AUGUST 2023

PRESENT

SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT

SRI.KUMARA.N, B.Sc. (Agri), LL.B., MBA., MEMBER

SMT.NIVEDITA RAVISH, B.A., L.L.B, LADY MEMBER

CC.No.59/2023

Sri. Shankara Sharma

Bhuvana Shree, 40 feet Road,

Sapthagiri Extension west,

Tumakuru-572 102,

Karnataka.

……….Complainant

(In person)

V/s

Star Health Insurance Company,

4^th Cross Road, M.G.Road,

Tumakuru, Karnataka.

……….Opposite Party

(By Smt.K.P.Mamatha, Adv.,)

:ORDER:

BY SMT.G.T.VIJAYALAKSHMI, PRESIDENT

The complainant filed this complaint U/s 35 of the C.P. Act alleging deficiency in service against the OP with a prayer to direct the OP to pay Rs.2,850/- towards annual health check-up and Rs.50,000-00 towards penalty for the deficiency of service.

2.       The brief facts of the complaint are as under:-

The complainant obtained health insurance policy with OP vide policy No.P11411131/01/2021/002836 which valid from 28.09.2020 to 27.09.2021.  Later, the said policy in the 2^nd term got converted into comprehensive insurance policy and the same was valid from 28.09.2021 to 27.09.2022.  The complainant further submitted that as per the said policy, the complainant is entitled for reimbursement of annual health check-up amount.  Hence, the complainant submitted the original bills for Rs.2,850-00 on 14.07.2022 to the OP.  But the OP in spite of repeated requests and demands did not settle the claim and even did not give any endorsement for rejection of the claim.  Hence, the complaint.   

3.       The OP appeared through its counsel after receipt of commission notice and filed the version contending that the complainant has obtained family health optima policy vide policy No.P/141131/01/2021/002836 by himself and to his spouse.  It is further contended that during 2^nd year of the policy, the complainant has migrated from above said policy to comprehensive policy vide policy No.P/141131/01/2022/002689 only in his name.  The provision to claim annual health check-up only in the earlier policy, while migrating the policy, the OPD claim has not been considered at earliest point and it is a technical error, so the claim of the complainant was not registered.  The OP tried to convince the same to the complainant on several times, but the complainant has not obliged.  The OPD coverage is Rs.1,500-00 only and not Rs.2,850-00 and moreover the complainant has not submitted any claim form along with documents.  It is further submitted that due to technical issue and migration, OPD balance showed as Rs.0/-  and therefore, the OP unable to register the claim and not able to settle the claim.  Hence, there is no fraudulent intention and also there is no any deficiency of service.  The compensation of Rs.50,000-00 claimed by the complainant is not sustainable.  The OP further submitted that when the parties have entered into a contract of insurance, they have to rely on the terms of the contract, hence the insurance company and the insured are to follow all terms and conditions of the policy correctly.  On these among other grounds, it is prayed to dismiss the complaint.           

4.       The complainant has filed his affidavit evidence. Sri. Manjunath T.L., Branch Manager has filed his evidence by way of affidavit on behalf of OP.  The counsel for OP marked the documents at Ex.R1 to R7. 

5.       We have heard the arguments from complainant in person and counsel for OP.

6.       On perusal of pleadings, affidavits and documents produced by both parties, the points that would arise for our consideration are:

1. Whether there is any deficiency in service on the part of OP?

2. Whether complainant is entitled for reliefs sought for?

7.       Our findings to the aforesaid points are as under:

Point No.1: Partly in the Affirmative

Point No.2: As per the final order.

:REASONS:

8.       On perusal of pleadings, evidence, documents and written arguments of the OP, we listed the admitted facts between the parties are:

The complainant obtained health insurance policy with OP vide policy No.P11411131/01/2021/002836 which valid from 28.09.2020 to 27.09.2021.  Later, the said policy in the 2^nd term got converted into comprehensive insurance policy and the same was valid from 28.09.2021 to 27.09.2022.  As per the policy, the complainant is entitled for reimbursement of annual health check-up amount and complainant submitted the original bills for Rs.2,850-00 on 14.07.2022 to the OP.  But complainant admitted that the annual check-up amount ceiling to  Rs.1,500-00 only. 

9.       The allegation of the complainant is that,  in spite of repeated requests and demands, OP did not settle the claim and even did not give any endorsement for rejection of the claim.  There is a delay in settlement of the claim and not properly treated the complainant when he visited the OP’s office to enquire about his reimbursement claim.  

10.       Per-contra, the OP contended that during 2^nd year of the policy, the complainant has migrated from above said policy to comprehensive policy vide policy No.P/141131/01/2022/002689 only in his name.  The provision to claim annual health check-up only in the earlier policy, while migrating the policy, the OPD claim has not been considered at earliest point and it is a technical error.  The OP further contended that the OPD coverage is only Rs.1,500-00 and due to technical issue and migration, OPD balance showed as Rs.0/-. Therefore, the OP was unable to register the claim and not able to settle the claim.  Without any fraudulent intention, the OP tried to convince the same to the complainant on several times, but complainant not obliged.  

11.       The counsel for OP put-forth proposal for settlement, but the complainant not agreed and rejected the settlement proposal.  The complainant submitted that when he visits the OP’s office, the OP shows callous attitude.  For that reason, he is not ready for settlement and requested for compensation for the callous attitude of the OP.

12.       Considering the above facts and circumstances, it is just and proper to direct the OP to pay the annual check-up charges of Rs.1,500-00.  For the delay in settlement of the claim and mental agony undergone/faced by the complainant and for the act of the OP, the complainant compelled to approach this Commission.  Hence, the OP is liable to pay Rs.5,000-00 as compensation and Rs.5,000-00 as litigation expenses.  Accordingly, we pass the following:-

:ORDER:

The complaint filed by the complainant is allowed in part with cost.

The OP is directed to pay Rs.1,500-00 towards annual check-up charges along with compensation of Rs.5,000-00 and litigation expenses of Rs.5,000-00 to the complainant within 45 days from the date of receipt/knowledge of the order.

Supply free copy of this order to both parties