Punjab

Ludhiana

CC/17/86

Tej Bahadur Kaur - Complainant(s)

Versus

Star Health & Allied Ins.Co.Ltd - Opp.Party(s)

compl.in person

04 Mar 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

 

Consumer Complaint No. 86 of  07.02.2017

Date of Decision            :   04.03.2021

Tej Bahadur Kaur aged 66 years wife of Sh.Harinder Singh Dhall through Harinder Singh Dhall son of S.Mohinder Singh, both residents of 304-C, Model Town Extension, Ludhiana.

….. Complainant

                                                         Versus

1.Star Health & Allied Insurance Company Limited, 2716, Ist Floor, Gagan Complex, Backside Majestic Park Plaza, Gurdev Nagar, Pakhowal Road, Ludhiana, through its Branch Manager/Authorized Signatory.

2.Star Health & Allied Insurance Company Limited, KRM Centre, VI Floor, No.2, Harrington Road, Chetpet, Chennai-600031..

Opposite parties

 

             (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

SH.K.K.KAREER, PRESIDENT

MS.JYOTSNA THATAI, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         In person Sh.Harinder Singh Dhall, representative of

complainant.

For OPs                          :         Sh.Rajeev Abhi, Advocate

 

PER K.K.KAREER, PRESIDENT

 

1.                This complaint under Section 12 of the Consumer Protection Act, 1986(hereinafter in referred to as ‘Act’) has been filed by the above named complainant on the allegations that the complainant got the individual health insurance policy No.P/161114/01/2016/005990 for Rs.2 lac from the OPs which was valid for the period from 08.11.2015 to 07.11.2016. The complainant has been paying the premium of the policy for the last seven years regularly. It is further alleged that on 15.03.2016, the complainant was admitted in Max Super Specialty Hospital, Mohali for the replacement of her both knees and after treatment she was discharged on 22.03.2016. Thereafter, the complainant applied with the OP1 for the payment of the medical expenses as per the terms and conditions of the policy and also submitted all the required documents. The complainant had spent more than Rs.4,87,969/- on her treatment. The complainant was having two policies, one with the OP1 and other with the Oriental Insurance Company Limited which was for a sum of Rs.3 lac. The complainant also approached the Oriental Insurance Company regarding her medical claim through Max Hospital and a claim of Rs.2,99,607/- was paid by the said company to the hospital under cashless scheme. The hospital gave discount of Rs.17,970/- to the complainant on the total bill. However, the balance amount of Rs.1,70,000/- which remained due towards the hospital expenses were paid by the complainant in cash against bill No.MHIC50915 dated 22.03.2016. The complainant had also incurred expenditure of Rs.31,580/- regarding which bills were submitted with OP1. The complainant approached the OP1 for the medical claim of Rs.2,01,580/- ,but she was paid only a sum of Rs.1,01,293/- and the remaining amount of Rs.1,00,287/- was not paid despite repeated demands and visits. Even a written request dated 14.09.2016 sent by the complainant to OP1 failed to evoke a positive response from the OPs. Hence this complaint whereby it has been requested that OPs be directed to make the payment of Rs.1,00,287/- along with Rs.75,000/- as compensation on account of mental pain, harassment and torture caused to the complainant and Rs.20,000/- on account of litigation expenses.

2.             The complaint has been resisted by the OPs. In the joint written statement filed by the OP1 and OP2, it has been pleaded that the complaint is not maintainable. According to the OPs, the complainant had obtained Medi Classic Individual Health Insurance Policy covering herself for a sum of Rs.2 lac from 3.11.2009 onwards. The claim was reported in the 7^th year of the policy for a sum of Rs.1,18,260/- regarding the treatment of the complainant from 15.3.2016 to 22.03.2016 with Max Super Specialty Hospital, Mohali for the treatment of Osteoarthritis. After scrutiny of the claim records, the claim was paid for a sum of Rs.1,01,293/- on 20.6.2016 vide DD No.560580 towards the full and final settlement of the claim which was accepted by the complainant voluntarily and unconditionally. The complainant had executed the discharge voucher on 23.06.2016 and DD for Rs.1,01,293/- was also encashed by the complainant. The OPs have further pleaded in the written statement that a sum of Rs.1,18,260/- was deducted strictly as per the terms and conditions of the policy. According to the OPs, as per clause (a) of the policy, the expenses relating to room, boarding, nursing as provided by the hospital/nursing home were payable at the rate of 2% of the sum insured, subject to maximum of Rs.5000/- per day and on this account, a sum of Rs.1400/- was deducted. Similarly, the consultancy charges, surgeon charges, anesthetic charges and OT charges were to be considered according to the availed room rent and therefore, deductions of Rs.400/-, Rs.1496/-, Rs.473/- and Rs.1346/- were made respectively. As per IRDA guidelines, the expenses towards mask, micropore, kit, electrode, gauzeswab, cover, gamjeeroll, pow free gloves, gown, drape, trolly sheet, abd gauze, apron, urometer, handrub, thermometer, spirometer, bed pan and urinal plastic were not payable and on this account, a sum of Rs.18,361/- was deducted. As per the preamble of the policy, the expenses towards emergency ambulance were only payable and amount of Rs.2000/- was deducted. As per clause (f), the expenses towards surgeon, consultant fee, diagnostic charges, cost of drugs and medicine would be taken into consideration for the post hospitalization charges and x-ray extra film charges and phyiso home visit charges were not payable and a sum of Rs.28,500/- was deducted on that account. Towards the claim of the complainant, the same was already settled for Rs.2,99,607/- under the Punjab Government Employees and Pensioners Health Insurance Scheme by MD India Healthcare Services (TPA) Pvt. Ltd. Therefore, there is no deficiency in service on the part of the OPs and the claim has been settled and paid which was accepted voluntarily and unconditionally by the complainant. The rest of the averments made in the complaint have been denied as wrong and in the end, a prayer for dismissal of the complaint has also been made.

3.                In order to prove the allegations made in the complaint, the complainant examined herself by tendering her affidavit Ex.CA and proved on record documents Ex.C1 and Ex.C20 and closed the evidence.

4.                On the other hand, the counsel for the OPs tendered in evidence affidavit Ex.RA of Sh.P.C.Tripathy, Zonal Manager of the OPs and proved on record documents Ex.R1 to Ex.R30 and then closed the evidence.

5.                We have heard the rival contention of counsel for the parties and have also gone through the written submission made by the OPs.

6.                The grievance of the complainant is that she was hospitalized from 15.03.2016 to 22.03.2016 with Max Super Specialty Hospital, Mohali for replacement of both knee and spent an amount of Rs.4,87,969/- on her treatment. The complainant was having two policies, one with the OP1 and the other with the Oriental Insurance Company in which the sum insured was Rs.3 lac. A sum of Rs.2,99,607/- was paid by the Oriental Insurance Company Limited under the cashless scheme. After taking into discount of Rs.17,970/-, the balance amount of Rs.1,70,000/- was due towards the hospital. In addition to this, the complainant has spent a sum of Rs.31,580/- more regarding which, the bills were submitted with the OP1. Thus the total amount claimed by the complainant from the OP1 was Rs.2,01,580/- out of which, she was paid only an amount of Rs.1,01,293/- and the remaining amount of Rs.1,00,287/- was not paid, which has been claimed by way of this complaint.

7.                To prove her case regarding non-payment of the bills amounting to Rs.1,00,287/-, the complainant has placed on record bills Ex.C7 to Ex.C13. Ex.C7 is a duplicate settlement receipt of Rs.1,14,893/- paid by way of credit card. Similarly, Ex.C8 and Ex.C9 are duplicate deposit/advance receipts of Rs.50,000/- and Rs.5500/- issued by Max Healthcare on 21.03.2016 and 09.03.2016 respectively. It is well settled that the insurance company is supposed to make the payment of the bills as per the terms and conditions of the policy and not on the basis of receipts. The complainant has not referred to any corresponding bills, payment of which was made vide receipts Ex.C7 to Ex.C9. Therefore, in the considered opinion of this Commission, the amount of receipts Ex.C7 to Ex.C9 cannot be said to be payable.

8.                The complainant has further placed on record another duplicate invoice cum receipt Ex.C10 dated 09.03.2016 for a sum of Rs.690/-. This receipt pertains to pre-hospitalization charges, which have not been paid by the OPs. In the bill assessment sheet Ex.C4, the reasons for non-payment of bill Ex.C10 is mentioned as ‘duplicate bill not payable’. Since the original of Ex.C10 has not been submitted with the OPs, the reasons given for non-payment seems to be justified. The complainant has further relied upon another duplicate invoice cum receipt Ex.C11 dated 05.04.2016 for a sum of Rs.1500/-. The complainant has further relied upon another duplicate invoice cum receipt Ex.C12. However, surprisingly no amount is mentioned in the duplicate invoice cum receipt Ex.C12 which is dated 05.04.2016 and pertains to post hospitalization period. Since no amount is mentioned in Ex.C12, the question of its payment did not arise. Even otherwise invoice Ex.C12 is also a duplicate one and original of the same has not been produced.

9.                The complainant has further relied upon receipt Ex.C13 for a sum of Rs.27,000/- issued by Care & Cure Physio & Wellness World. This receipt pertains to home visit by a Physiotherapist. As regard Ex.C13 and Ex.C11, reasons given by the OPs for non-payment is that x-ray extra film charges and physio home visit charges are not payable as per the terms and conditions of the policy as is evident from bill assessment sheet Ex.C4. Even otherwise as per Ex.R8, which are terms and conditions of the policy, the post hospitalization expenses incurred upto 60 days after the discharge from the hospital are not supposed to exceed a sum equivalent to 7% of the hospitalization expenses subject to a maximum of Rs.5000/- per hospitalization and further that for the purpose of calculation of the 7%, only nursing expenses, surgeon’s/consultants fees, diagnostic charges and cost of drugs and medicine are to be taken into account. Therefore, it is obvious that physiotherapy charges are not admissible or payable as per the terms and conditions of the policy. Therefore, it cannot be said that out of the claim of Rs.2,01,580/- lodged by the complainant with the OPs, the rejection of claim to the extent of Rs.1,00,287/- was not justified. On the contrary, it is evident from the record that the claim to the extent of Rs.1,00,287/- was not at all payable, as pointed out on the foregoing part of the order and has rightly been rejected.

10.           As a result of the above observation, the complaint fails and the same is hereby dismissed, being devoid of any merit. Keeping in view, the peculiar circumstances of the case, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules.

11.              File be indexed and consigned to record room.

12.              Due to rush of work and spread of COVID-19, the case could not be decided within the statutory period.

 

                     (Jyotsna Thatai)                                     (K.K.Kareer)

             Member                                         President

Announced in Open Commission

Dated:04.03.2021

Gurpreet Sharma.