Delhi

East Delhi

CC/1169/2014

DEEPAK - Complainant(s)

Versus

STAR HEALTH - Opp.Party(s)

09 Jul 2018

ORDER

              DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

                 CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.    1169/2014

                                                                                                   Date of Institution              24/12/2014

                                                                                                   Order reserved on               09/07/2018        

                                                                                                   Date of Order                       11/07/2018                                                                                     

 

In matter of

Mr Deepak Bansal, adult   

R/o- 4, DDA Flats,

Masjid Moth, Phase I, New Delhi 110048…………………...………Complainant

                             

                                      Vs

1-The Manager

Star Health Insurance Co. Ltd.

HO- 209-210, Laxmi Deep Building,

District Centre, Lamxi Nagar, Delhi 110092…….………………….Opponent

 

Complainant’s Advocate        Aziz Ullah & Abhishekh Singh     

Opponent  Advocate               Naveen Kumar  

 

Quorum                                     Sh Sukhdev  Singh      President

                                                    Dr P N Tiwari                Member

                                                    Mrs Harpreet Kaur      Member                                                                                             

 

Order by Dr P N Tiwari  Member -

Brief -

This complainant has been filed u/s 12 of the Consumer Protection Act, 1986 against OP for alleged deficiency in services for deducting claim amount under cashless facility.   

Facts of the case-                                                                                                

Complainant, Deepak Bansal, took Star Senior Citizens Red Carpet Insurance mediclaim policy from Star Health and Allied Insurance Co. Ltd./ OP from 24/11/20107 to 23/11/2008 for a sum insured One Lac vide policy no. P/161100/01/2008/00768 for his mother Smt Satyavati Bansal which was renewed from 02/12/2008 to 01/12/2009 and till 01/12/2011 vide policy no. P/161111/01/2011/003770 under one lac sum assured and declared high blood pressure and Glaucoma which she had prior to inception in policy proposal form, so OP had put these ailments under permanent exclusion, which was continued.  

 

Complainant enhanced her mother’s mediclaim policy for 3 lacs from one lac from 02/12/2011 to 01/12/2012 (Ex CW1/1 & 1A) in policy no. P/161111/01/2011/003770 and renewal policy was issued with all terms and conditions in policy P/161111/01/2012/004329 having tenure 02/12/2011 to 01/12/2012.

It was stated that his mother was admitted at Atul Nursing Home, Agra for Fracture Right Hip joint on 11/11/2011 and was discharged on 13/11/2011. The hospital bill Rs 6802/- was claimed, but OP paid only Rs 4200/-(Ex CW1/3) which was credited in the account of complainant for Fracture Right Femur. It was stated that his mother was readmitted to Batra Hospital Delhi on 28/11/2011 and was discharged on 13/12/2011 for “Arthroplasty in Fracture Right Femur” (Ex CW1/4). The complainant claimed treatment Rs. 2,80,257/ under the existing claim policy of 2010-2011 vide policy no. P/161111/01/2011/003770 having sum insured amount Rs One Lacs, but OP cleared bill for Rs 59,5000/-(Ex CW1/4A). After some time, his mother was again admitted in Kailash Hospital, Noida for Gastritis and remained admitted from 19/01/2012 to 21/01/2012. The hospital bill of a sum Rs 16367/- was claimed which was cleared for Rs 7508/-(Ex CW1/5).

 

Complainant stated that he was not satisfied by the attitude of OP for maximum deductions in his father’s claim and all three claims of his mother, so he filed his complaint for his father to Insurance Ombudsman, Delhi on 14/11/2011 vide case no. GI/378/Star/11 against OP as his father had undergone CABG at Delhi hospital and claimed under policy no. P/16111/01/11/003771, which was settled by OP. The complainant filed his mother’s case before Delhi Ombudsman vide case no. G/25/Star/12 on 04/05/2014. The case was disposed on 11/11/2014 with order that “We (Delhi Ombudsman) were satisfied by OP services in claim process. If you (the complainant) were not satisfied, may approach to any Forum for redressal”. By seeing callous attitude of OP and outcome of order of Ombudsman, filed this complaint for the reimbursement from OP by claiming Rs 2,16,000/-and compensation for mental and physical harassment Rs 2 lacs  with legal expenses Rs 50,000/-.

 

 

OP submitted written statement denying all the facts and allegations of deficiency in services. It was submitted that the complainant was an educated person and had gone through all the terms and conditions of this Red Carpet mediclaim policy made for senior citizens. Policy was issued to insured/claimant Smt. Satya Vati Bansal where insured had disclosed Hypertension and Glaucoma as pre existing ailments so these two ailments and their complications were put under permanent exclusions.

 

OP issued policy vide no. P/161100/01/2008/000768 from 24/11/2007 to 23/11/2008 having one lac sum insured. In second year renewal, there was gap of 8 days, so policy was issued from 02/12/2008 to 01/12/2009 and got renewed till 01/12/2011 with same one lacs sum insured.

The insured/claimant as mother of the complainant got right femur neck fracture in old case of severe osteoporosis. She was admitted from 11/11/2011 to 13/11/2011 at Agra and claimed amount of Rs 4242/ which was reimbursed vide claim no. DD 635983 under policy P/161111/01/2011/003770 having one lacs sum insured.

 

Complainant’s mother was readmitted at Batra Hospital in New Delhi on 28/11/2011 for Arthroplasty in right femur neck fracture and was discharged on 13/12/2011. The claim was processed under the P/161111/01/2011/003770 with one lacs sum insured, whereas complainant had claimed a sum of Rs 2,80,257/- so net payable amount Rs 63700/- was paid vide claim no. 650675 on dated 30/01/2012 under policy provision conditions A to G. As total hospital bill of Batra hospital was Rs 2,80,257/-, but under the policy conditions, all excess charged by the hospital were contrary to the terms and conditions,    hence excess amount of Rs 2,20.757/- were deducted and balance amount Rs 59,500/- were approved for the cashless and the same was paid to the hospital. It was stated that OP could not pay beyond sum insured amount (one lacs).

 

It was also stated that the complainant had not only enhanced his mother’s policy from one lacs to 3 lacs from 02/12/2011 when his mother was readmitted in Delhi on 28/11/2011 and did not disclose to OP about the admission, whereas the treating hospital had sent cashless request which was approved subject to the terms and conditions of the claim policy. It was submitted that enhanced amount (2lacs) was not applicable for immediate benefits under the policy conditions, but subject to limitations for claim processes as per the policy table. Here in this case, complainant’s mother Smt Satyavati was insured for a sum of Rs one lacs from 2007 till 01/12/2011. Insured/Claimant had her femur neck injury in Nov.2011 and was paid the first hospital bill of Agra. Batra hospital bill was under the enhanced sum, but OP had already paid under the previous policy no. P/16111/01/2011/003770 and the same sum insured was considered under P/161111/01/2012/004329 for one lacs and paid cashless amount to the hospital.

 

But complainant had intentionally filed this case to get the monetary benefits from this Forum where he himself was an educated person and  read over all the terms and conditions of the policy for his mother who himself was a proposer and not a claimant or insured. Under the terms of the policy, enhanced sum insured (from One lacs to Three lacs) were not payable to the claimed ailment for which Co./OP had already paid the claim earlier for fracture neck femur. But complainant was demanding reimbursement of entire treatment bill of Batra hospital on enhanced sum insured.  Hence, OP prayed for dismissal of this complaint.  

 

Complainant filed his rejoinder and denied all the replies submitted by OP and stated that his genuine claim was wrongly paid against his claim under continuation tenure of the policy and stated that all his contents and facts of the complaint were correct. Complainant submitted all relevant evidences on affidavit signed by himself where he reaffirmed on oath that all facts and evidences were correct and true. He filed his policy details as Ex CE1/1 as third year policy copy as claim policy having sum insured of his mother one lacs vide present policy no. P/16111/01/2011/003770 where previous year policy was a continuous one vide its no. as P/161100/01/2010/0065059. He also exhibited as Ex CE1/1A as terms and conditions containing 9 pages.

Complainant also submitted Ex CE1/3 as enhanced sum insured policy of three lacs from one lacs vide policy no. P/161111/01/2012/004329 for 02/12/2011 to 01/12/2012. Complainant also stressed on bill Assessment Sheet of OP pertaining to Batra Hospital, Delhi where he claimed bill of Rs 2,80,257/- and OP approved Rs 59,5000/-only under policy P/16111/01/2011/003770 with sum insured One Lacs and another evidence as Ex CE1/5 under policy no. P/161111/01/2012/004329. Hence, it was stated on oath that the exhibited evidences were correct.       

OP also submitted their evidences by way of affidavit through Mr Rajnish Kohli working as Assist. Vice President claims with OP stated that all their evidences and replies to the complaint were correct and true, It was also stated that policy was issued on the basis of good faith. OP stated that all two claims pertaining to policy no. P/16111/01/2011/003770 (Ex OPE1/1) were processed under claims 123597 and 93016. It was submitted that if claim made between two policy periods as in this case where previous policy had one lacs sum insured and was enhanced to three lacs, but OP had paid for the same ailment under the same policy then enhanced claim would not be considered under any policy terms and conditions.

The Batra Hospital bill claimed by the complainant for sum assured Four lacs had no weight as there was only ONE policy of ONE Lacs sum insured for Smt Satyavati vide policy no. P/16111/01/2011/003770 having tenure from 02/12/2010 to 02/12/2011. Under this policy,  sum assured was enhanced to THREE Lacs from 02/12/2011 to 01/12/2012 vide policy no. P/161111/01/2012/004329. Whereas complainant had claimed as two policies and sum insured had to be clubbed for claim purposes which did not support with any terms and condition of the policy.

OP stated that as per Ex OPE1/3, complainant was issued Star Senior Citizen’s Red Carpet Insurance Policy where payable clauses were enhanced as a special benefits under this policy which were as under-

i-Room charges were enhanced to 4000/- per day instead of 1% to sum insured.

ii-ICU charges were enhanced to 2% to sum insured instead of 1%.

iii-Medical services to 25% of sum insured.

 

• All operative procedures, Lab procedures were enhanced to 50% to sum insured.
• Emergency Ambulance charges were allowed to 1200/- which were not admissible.
• Post hospitalization expenditure was enhanced to 5000/- per occurrence.
• All major and minor surgeries where day care required, claim limit was also enhanced as per table.

It was also stated that average claims ratio of preceding 2 years consecutive would have loading on premium every year as per column 9 of conditions. It was also stated that complainant had every time went to Ombudsman to take undue advantage without any merits.

Hence, OP submitted their evidences on affidavit were true and correct and there was no deficiency in their services and the complainant was neither a claimant nor insured, so this complaint may be dismissed with cost. 

Both the parties submitted their written arguments and taken on record. Arguments were heard from Ld counsels of both the parties. File was perused and order was reserved.  

It has been noted that complainant is a proposer of the policy for his mother Smt Satyavati Bansal, but not a claimant or insured, so this means there is no contract between insured and OP. In this context, a proposer cannot be said to be insured or claimant, but could be a power of attorney holder or authorised person to take part in the proceedings, but complaint has filed this complaint and also singed affidavit. There were nowhere signatures of insured/claimant, Smt Satyavati Bansal, so how a proposer can enter under the contract and a direct beneficiary of OP. More so, there were no hospitals break up bills, treatment papers, medicines bill, lab reports except documents pertaining to Ombudsman proceedings and their orders. Complainant had not filed any claim details from OP taken earlier to Nov. 2011. Complainant also could not file any evidence to show that clubbing of sum insured under policy was evidence under policy terms and conditions in policy. Also complainant could not prove that being a proposer he has locus standi to file the complaint and take benefit from OP in absence of contract and insurable interest.

 

   

Thus, we find no merit in this complaint and complaint deserves to be dismissed so dismissed with cost  Rs 2000/-  which  will be deposited with the Legal Service Authority of East Delhi, Karkarduma, Delhi 32 within 30 days from the date of order and the acknowledgment be submitted in the record file.   

The copy of this order be sent to the parties as per the Section 18 (6) of the Consumer Protection Regulation, 2005 ( in short CPR)  and file be consigned to the Record Room under Section 20(1) of CPR.

 

(Dr) P N Tiwari  Member                                                                      Mrs  Harpreet Kaur  Member                                                                                                                        

                                      

                                                   Shri  Sukhdev Singh  President