Chandigarh

DF-I

CC/524/2013

Aneesh Mitra - Complainant(s)

Versus

Star Health - Opp.Party(s)

23 Feb 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/524/2013
Date  of  Institution	:	18/09/2013
Date   of   Decision	:	23/02/2015

 

 

 

 

 

Aneesh Mitra Bhanot R/o H.No.3727, Sector 46-C, Chandigarh.

 

…Complainant

Versus

 

Star Health & Allied Insurance Company Limited, SCO No.101, 102 & 103, 2^nd Floor, Batra Building, Sector 17-D, Chandigarh – 160017, through its Insurance Ombudsman.

 

Fresh Address:

Star Health & Allied Insurance Company Limited, SCO No.257, 2^nd Floor, Sector 44-C, Chandigarh - 160044.

 

     …Opposite Party

 

BEFORE:    SH. JASWINDER SINGH SIDHU  PRESIDING MEMBER

MRS.SURJEET KAUR                MEMBER

                     

Present:      Ms. Harpriya Khaneka, Counsel for Complainant.

Sh. Gaurav Bhardwaj, Counsel for Opposite Party.

 

 

PER JASWINDER SINGH SIDHU, PRESIDING MEMBER

 

 

1.      Sh. Aneesh Mitra Bhanot, Complainant, has filed this Consumer Complaint under Section 12 of the Consumer Protection Act, 1986, against Star Health & Allied Insurance Company Limited (hereinafter called the Opposite Party), alleging that he took Health Insurance Policy, from the Opposite Party, valid for the period from 09.08.2012 to 08.08.2014, for the sum assured to the tune of Rs.3 lacs, with sub-limit of Rs.1.50 lacs, on account of illness, arising out of pre-existing disease i.e. diabetes. It has been averred that during subsistence of the said Policy, the complainant was admitted to Fortis Hospital, Mohali, on three different occasions, on account of sudden severe headache, vomiting, high sugar, high blood pressure etc. The complainant paid the total amount of Rs.1,05,300/-, on account of his treatment, to the said Hospital. Subsequently, the complainant filed three separate claim forms, for reimbursement of the aforesaid amount, paid by him, on his treatment. It has been further averred that, on the other hand, the Opposite Party, on 19.07.2013, sent demand draft, in the sum of Rs.8,565/-, towards full and final settlement of the claims. It has been further averred that the complainant contacted the Opposite Party, a number of times, to redress his grievance, by paying the balance amount of Rs.96,735/-, but to no avail. It has been stated that the aforesaid acts of the Opposite Party, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant has not been redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), has been filed, directing the Opposite Party, to  pay the balance claim amount of Rs.96,735/-, alongwith interest @12% P.A., from the date of filing the same (claim), till realization; compensation, to the tune of Rs.50,000/-, for deficiency, in rendering service; and cost of litigation, to the tune of Rs.22,000/-.

 

2.      Notice of the complaint was sent to Opposite Party seeking its version of the case.

 

3.      Opposite Party has filed its reply, inter alia, admitting the factual matrix of the case. It has been pleaded that the Complainant was paid, whatever was payable as per the terms and conditions of the policy after due application of mind by the answering Opposite Party. The amount was calculated after proper scrutiny of the claims. It has been further pleaded that the Hospitalization of more than 24 hours is covered except some treatment/ disease. Since the Hospitalization in respect of the first two claims was less than 24 hours, the same were not payable. The third claim was paid to the tune of Rs.8565/- as per terms and conditions of the policy. The Complainant is not entitled to the full amount of the claims. Denying all other allegations and stating that there is no deficiency in service on its part, Opposite Party has prayed for dismissal of the complaint.

 

4.      Parties were permitted to place their respective evidence on record in support of their contentions.

 

5.      We have heard the learned Counsel for the parties and have also perused the record, along with the written arguments filed on behalf of both the parties.

 

6.      The Complainant has preferred the present Complaint against the Opposite Party on the ground that he had subscribed for Health Insurance Policy which was specifically tailor made for a two years period and the same was valid for the period 9.8.2012 till 8.8.2014 as per the terms and conditions, which are annexed at Annex.C-1. The Complainant was admitted to Fortis Hospital, Mohali, on three different occasions after having suffered a severe onset of Headache, Vomiting, High Sugar, High Blood Pressure etc., which necessitated immediate hospitalization. On the three different occasions, the Complainant was admitted to the Hospital on 2.6.2013, 4.6.2013 to 5.6.2013 and 5.6.2013 to 7.6.2013 and an amount of Rs.28290/-, Rs.39,462/- and Rs.36,918/- respectively, was spent towards hospitalization, medicines and investigations. The Complainant had duly submitted the claim forms against each such claim, which are annexed as Annexure C-2, C-3 and C-4 respectively, amounting to Rs.1,05,300/- but is aggrieved of non-settlement of his entire claim and has disclosed that a demand draft amounting to Rs.8565/- was received at his end against the collective payment of Rs.1,05,300/-. The Complainant has placed on record the letter Annexure C-5 which was received along with the payment of Cheque towards the partial settlement of the claim.

 

7.      The Opposite Party has held its ground while defending itself against the present Complaint qua it and ha referred that the settlement of the claim of the Complainant was as per the terms and conditions of the policy which according to them have been annexed by the Complainant himself as Annexure C-1. The Opposite Party has also claimed that apart from the exclusions there were other deductions which were made as the entire bill amount was not paid for the reason that the Opposite Party was not liable to pay any expenses which were not included towards the expenses on medicine, diagnosis and hospitalization. Thus claiming no deficiency in service on its part, has prayed for dismissal of the Complaint.

 

8.      We have perused the terms & conditions of the policy and also the exclusion clause, which clearly indicates that it was necessary for the Complainant to have remained admitted in the Hospital for at least 24 hours, so as to qualify for the settlement of the claim towards his hospital expenses. The Opposite Party has referred to the terms & conditions of the policy, wherein, it is categorically mentioned that expenses on hospitalization as an ‘inpatient’ was payable as per the clauses A to F of Annexure C-1 and for this purpose, a patient has to remain hospitalized for a minimum period of 24 hours to qualify as an indoor patient, for the Opposite Party to settle the claim in such terms. Whereas, certain diseases which do not require a 24 hours admission period have been specifically mentioned.

 

9.      It is admitted case of the Complainant that he remained hospitalized only for 1½ hour on 2.6.2013 and after necessary investigations the doctor had declared him to be suffering from TIA and Vertigo. It is necessary to quote the abbreviation TIA in its full form and according to the medical terminology, the same means ‘Transient Ischemic Attack’, which occurs when blood flow to a part of the brain stops for a brief time. Therefore, the investigations conducted were certainly in consonance with the disease, which was conservatively managed by keeping the patient under observation for a brief period. It is also very much apparent that the Complainant was again admitted on 4.6.2013 with a similar condition and remained hospitalized till 7.6.2013 after having been briefly discharged for a few hours on 5.6.2013 and during this stay, the Complainant was once again diagnosed with same TIA, meaning thereby that there was no new disease but a relapse of the condition that had occurred to him on 2.6.2013. Therefore, as per terms & condition of the policy which clearly mentions that if a similar disease occurs within 45 days of its first happening, the condition is to be declared as a continuous one.

 

10.      Though the Opposite Party while declaring that it had promptly settled the claim of the Complainant, as per the terms & conditions of the Policy, and having declared that his claim against Bill No. 2962 for an amount of Rs.29,729/- was settled and was paid an amount of Rs.8565/- and while settling this claim a letter dated 19.7.2013 was sent by the office of the Opposite Party. The last lien of this communication reads as “The detailed breakup of claimed amount in acceptance is enclosed”. However, there is no other document found attached to this letter from where the true settlement of the claim could be adduced. The Opposite Party while filing its reply has not placed on record any other document apart from its affidavit. Therefore, it is not possible for us to understand that in what terms an amount of Rs.8565/- was calculated. It is necessary to quote here that the amount of bill which they claimed to have settled including two days rent to the tune of Rs.13,750/-, apart from amount of Rs.1357/- towards medicines, Rs.1876/- towards consumables, Rs.1930/- towards consultation charges, Rs.550/- towards imaging (X-ray Spine – Cervical) and Rs.8683/- on account of investigations were charged apart from food, beverages, donations etc. which were not payable. Therefore, the Opposite Party had preferred to pay a frugal amount of Rs.8565/- of which Rs.6000/- was the entitlement towards the room rent as per the policy conditions and the remaining Rs.2565/- was paid towards other expenses, a break-up of which has not been supplied to the Complainant, nor the same has been placed before this Forum, so as to believe the genuineness of the settlement of the claim of the Complainant, which amounts to deficiency in service on the part of the Opposite Party.

 

11.      Interestingly, the Opposite Party preferred to ignore the second claim amounting to Rs.17,365/- when the Complainant was admitted in the hospital on 4.6.2013 at 10.17 a.m. and was discharged on 5.6.2013 as per the Medical Certificate at page 33 of the paper book, wherein the time of discharge has not been mentioned. However, on perusal of the bill at page 34, it is abundantly clear that the Complainant was charged Rs.7250/- which included room rent charge of Rs.6500/- + Rs.750/- towards triage room charges, is indicative enough that the Complainant had stayed for 24 hours to qualify for the payment of Rs.6500/-, as compared from the bill no. 2962 of 7.6.2013 which was settled by the Opposite Party. Therefore, Complainant was certainly entitled to an amount of Rs.3000/- towards the room rent and also the other expenses incurred by him on his stay which was certainly for 24 hours to be declared as an inpatient, as per the terms & conditions of the policy. The non-settlement of the claim of the Complainant towards his second claim dated 5.6.2013 by the Opposite Party too amounts to deficiency in service on its part.

 

12.      In view of the foregoing discussions, the present Complaint deserves merit and the same is allowed. The Opposite Party is directed to assess the claim raised by the Complainant vide Annexure C-3 and C-4, afresh, disclosing each & every amount, which is payable or if not payable, valid reason for its non-payment, within a period of 30 days of the receipt of the certified copy of this order.

 

13.      The Opposite Party is also directed to pay a compensation of Rs.15,000/- on account of deficiency in service and causing mental agony and harassment to the Complainant, apart from costs of litigation to the tune of Rs.7,000/-, to be payable to the Complainant within 30 days of the receipt of the certified copy of this order, failing which the Opposite Party shall pay the entire claimed amount as per Annexure C-3 and C-4, along with interest @18% per annum from the respective dates of the bills, till it is paid. The compensation amount of Rs.15,000/- too shall carry interest @18% per annum from the date of this order, till it is paid, apart from cost of litigation of Rs.7,000/-, from the date of institution of this complaint, till it is paid.

 

14.      Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

23^rd February,2015                                     Sd/-

(JASWINDER SINGH SIDHU)

PRESIDING MEMBER

 

Sd/-

 (SURJEET KAUR)

“Dutt”                                                         MEMBER