D.O.F:28/01/2020
D.O.O:30/06/2022
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION KASARAGOD
CC.No.21/2020
Dated this, the 30th day of June 2022
PRESENT:
SRI.KRISHNAN.K :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
Biju Joseph
Poovathinkal
Bheemanadi.P.O : Complainant
Kasaragod - 671314
(Adv: K.P. Pradeep Kumar)
And
Star Health Insurance
Thaliparamba (br)
2nd Floor Ajru Tower : Opposite Party
Bank St. Thaliparamba
(Adv: C. Damodaran)
ORDER
SRI.RADHAKRISHNAN NAIR.M : MEMBER
The complaint is filed for compensation on the ground of service deficiency on the part of the opposite party.
The facts of the case in brief is that the complainant, who is the holder of a Family Health optima insurance policy of the opposite party, met with an accident and sustained grievious injuries on his leg and was taken to Thalassery Co-Operative Hospital and from there shifted to AJ Hospital, Manglore and treated there for one month till he was discharged on 13.06.2019. The Complainant had spent an amount of Rs. 2,74,239/- at AJ Hospital Manglore and Rs.2,000/- at Co-Operative Hospital Thalassery. But the opposite party paid only Rs.2,00,000/- towards Hospital Bill. As per the terms and conditions of Family Health optima insurance policy the complainant is entitled to get claim up to Rs. 6,75,000/- Since the opposite party was not ready to pay the entire Hospital Bill, the complainant was put to great hardships. There is service deficiency on the part of opposite parties and hence this complaint is filed for a direction to the opposite parties to pay the balance amount in hospital bill, along with compensation and cost.
The opposite party entered appearance through their counsel and filed written Version.
As per the written version of the opposite party the complaint is not maintainable either in law or on facts.
It is admitted that the complainant had taken a Family Health optima insurance policy for a period from 18.08.2016 to 18.10.2017, which has been renewed up to 18.10.2020. with a sum insured of Rs. 3,00,000/- vide. Policy No. P/181322/01/2020 / 003185. It is also submitted that during the 3rd year policy period, ie: from 18.09 .2018 to 17.09. 2019 vide . Policy No. P/181322/01/2019 / 002038 for a sum insured of Rs 5,00,000/- received request for cashless facility for the treatment of the complainant, from AJ Hospital, Mangalore and the opposite party sanctioned Rs.1,99,228/- allotting maximum amount in various heads as per terms and conditions of the policy. After discharge from hospital, the complainant had submitted claim form with discharge summary bills of Rs.75,011/- and reports for the balance of cashless. The opposite party had caused a query letter dated 01.08. 2019 to the complainant directing him to submit the prescription and consultation papers. As there was no reply to the said letter in spite of reminders, the opposite party closed the file and rejected the claim and informed the complainant as per letter Dated 15.09.2019. There is no service deficiency on the part of the Opposite Party. The complaint is liable to be dismissed.
The complainant filed proof affidavit in lieu of chief examination and documents Ext. A 1 to Ext. A 7 are marked .The Ext - A1 is the Discharge Summary dated. 13.06.2019, Ext. A 2 and Ext A3 are Renewal Receipts , Ext. A4 Series are the Medical Bills (18 in number) , Ext - A 5 is the certificate issued by SI of Police Darmadam, Ext A6 series are Photographs (5 in number ), Ext A 7 is the photo CD.
The opposite party did not adduce any oral evidence but produced certain documents and marked as Ext. B1 to Ext. B9 . The document Ext B1 is the Family Health Optima Insurance Plan , Ext.B 2 is Authorization for cash Iess treatment of the complainant dated 14.05.2019 , Ext. B3 is Authorisation for interim enhancement of the amount dated 08.06.2019, Ext. B4 is Authorization for cash Iess treatment of the complainant dated 13.06.2019, Ext. B5 is Authorization for final enhancement of the amount dated 13.06.2019, Ext. B6 is copy of Query letter dated 01.08.2019 issued by Opposite party to the complainant, Ext. B7 and B 8 are Reminder letters. Ext. B9 is the Rejection Letter dated 15.09.2019.
Based on the pleadings and evidence of the rival parties in this case, the following issues are framed for consideration.
1. Whether the complainant is entitled for any further amount towards the
insurance benefit ?
2. Whether there is any service deficiency on the part of any of the opposite party?
3. If so, what is the relief?
For convenience, all these issues are considered together.
Here the specific case of the complainant is that he had valid Family Health optima insurance policy for the period from 27.02.2019 to 26.02.2020 and was injured at his legs and was treated at Thalassery Co- Op. Hospital and thereafter at AJ Hospital, Mangalore , till 13.06.2019, but the opposite party did not pay the entire Hospital Bill by way of cashless facility. The Hospital bill was Rs.2,74,239/- at AJ Hospital Manglore but the opposite party paid only Rs.2,00,000/-.
The complainant's Counsel further argues that as per the terms and conditions, he is entitled to get claim up to Rs. 6,75,000/- including bonus, but in spite of that the opposite party paid only Rs.2,00,000/-.
The opposite party admit that the complainant had taken a Family Health optima insurance policy for a period from 18.08.2016 to 18.10.2017, which has been renewed up to 18.10.2020., with a sum insured of Rs. 3,00,000/- vide. Policy No. P/181322/01/2020 / 003185. It is also admitted that during the 3rd year policy period, ie: from 18.09 .2018 to 17.09. 2019 vide. Policy No. P/181322/01/2019 / 002038 for a sum insured of Rs 5,00,000/-.
The opposite party submit that after discharge from hospital, the complainant had submitted claim form with discharge summary bills of Rs.75,011/- and reports for the balance of cashless. The opposite party had caused a query letter dated 01.08. 2019 to the complainant directing him to submit the prescription and consultation papers. As there was no reply to the said letter in spite of reminders, the opposite party closed the file and rejected the claim and informed the complainant as per letter Dated 15.09.2019. The counsel of the complainant argue that the opposite party had collected entire documents relating to the treatments including prescriptions and consultation papers, of the complainant, from the hospital directly. The complainant is not in custody of that document and there is no necessity of producing the very same documents by the complainant.
Here the opposite party has no case that the complainant was not hospitalized or not treated. It shall be presumed that it was after verification of the necessary treatment records the opposite party issued Ext B2 to B5 authorizations. The opposite party did not produce the file relating to the complainant’s cashless claim, to show that they were not in receipt of the documents namely, prescriptions and consultation papers, of the complainant.
The main purpose of a health insurance policy is to offer monetary compensation to the policy holders in case of a medical emergency and the insurer is responsible to pay insurance benefit for medical expenses incurred during the validity period of policy. The opposite party argues that the insurance under the policy is subject to conditions clauses, warranties, exclusions etc. attached. The opposite party describes in their written version in detail as to how they arrived at the amount. The schedule shows the deduction made in various heads. Amounts are deducted in Room rent & Nursing charge (Rs.3,501/-), professional charges (Rs.11,641/-), investigation & diagnostics (Rs.900/-), Medicines and consumables (Rs.10,256/-), Composite packages (Rs.2,513/-), and others (Rs.46,200/-). The opposite party states that the calculation is as per the terms and conditions of the Policy. The Opposite Party further submits that even if this commission finds any liability upon the Opposite Party , then it may be limited to Rs.11,641/-.
It is clear that the above amount is that portion of amount deducted from professional charge. Admittedly complainant’s Policy No. P/181322/01/2019 / 002038 is for a sum insured of Rs 5, 00,000/-. As per policy, the complainant is entitled for single standard A/C Room. But the Opposite Party sanctioned only @ Rs.1750 /-for room rent for 9 days and deducted Rs.3,501/- So it appears that deductions in various heads are not as per the policy and the Opposite Party calculated the amount in order to minimize the quantum of insurance benefit and cause loss to the complainant.
Therefore considering the facts and circumstance of the case, the complaint is entitled for the medical expenses incurred for his treatment. So this commission is of view that the complainant is entitled for the Rs.74,239/- towards the balance in medical expense. Denial of the amount for no valid reason is service deficiency on the part of opposite parties, due to which the complainant suffered mental agony. Therefore the Opposite Party is liable to pay compensation for that. This commission hold that Rs.10,000/- will be a reasonable amount of compensation.
ln the result , the complaint is allowed in part and the Opposite Party is directed to pay a total amount of Rs.74,239/- with 8% interest per annum from 28.01.2020, the date of complaint till payment, to the complainant. He Opposite Party is also directed to pay Rs. 10,000/- towards compensation for mental agony and hardships and Rs. 5,000/-towards the costs.
Time for compliance is 30 days from receipt of the copy of the Judgement.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Discharge summary
A2 & A3- Renewal receipts
A4- medical bills
A5- Certificate issued by SI of Police Darmadam
A6- Photographs
A7- Photo CD
B1- Family Health Optima Insurance Plan
B2- Authorization for cashless treatment of the insured patient Dt: 14/05/2019
B3 - Authorization for interim enhancement of the amount Dt: 08/06/2019
B4- Authorization for cashless treatment of the insured patient Dt: 13/06/2019
B5- Authorization for final enhancement of amount Dt: 13/06/2019
B6- Query letter
B7 & B8 – Reminder letters
B9- Rejection Letter.
Witness Examined
Pw1- Biju Joseph
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
Ps/
