Order by:
Sh.Mohinder Singh Brar, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that the complainant purchased/renewed Medi claim policy bearing no.P/211/222/01/2022/008440 from Opposite Party valid for the period w.e.f 05.01.2022 to 04.01.2023 having sum insured of Rs.4,85,000/- against the payment of premium of Rs.21,081/- for himself and for his wife under ‘Family Health Optima Insurance Plan’. This is the continuous policy of previous policy bearing no.P/211222/2021/006755 which was earlier valid for the period 05.01.2021 to 04.01.2022 and the complainant has been purchasing the policy from the last so many years continuously and paid a hefty amount to Opposite Party on account of premiums. Unfortunately, during the policy period on 19.06.2022, the complainant needs to be hospitalized and admitted to Hunjan Hospital, Ludhiana for his medical treatment, where he remained admitted upto 25.06.2022 and spent Rs.2,18,371/- in the said hospital. Further alleged that as per the instructions of Opposite Party, the complainant got himself treated from Hunjan Hospital, Ludhiana being the network hospital of Opposite Party. At the time of discharge from the hospital, the complainant’s son made a request to the Opposite Party to make the payment of Rs.2,18,371/- being the medical bills to the treating hospital as the policy purchased by the complainant was cashless, but the Opposite Party refused to pay the same and only paid a sum of Rs.67,500/- to the treating hospital, so under the compelling circumstances, after discount, the remaining amount of Rs.1,43,371/- has been paid by the complainant from his own pocket. In this way, the Opposite Party withheld the claim of Rs.1,43,371/- illegally. Thereafter repeated requested have been made to the Opposite Party to make the payment of remaining amount of Rs.1,43,371/-, but to no effect. Aforesaid act and omission on the part of the Opposite Party amounts to great deficiency in service and unfair trade practice. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite party may be directed to reimburse the balance medical claim of the complainant which is amounting to Rs.1,43,371/- alongwith interest @ 12% p.a. from the date of payment to the respective hospital till its actual realization.
b) To pay an amount of R.2,00,000/- as compensation on account of damages for physical as well as mental pain and agony suffered by the complainant.
c) To pay an amount of Rs.18,000/- as litigation expenses.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is filed without any cause of action. Further alleged that the present complaint pertains to insurance claim under Family Health Insurance Policy No. optima bearing P/211222/01/2022/008440 valid from 05.01.2022 to 04.01.2023 covering the complainant self and his spouse Baljinder Kaur for a sum of Rs 3,00,000/-. However the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Moreover the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Therefore it is submitted that in case if any liability would arise against the answering Opposite Party, then it would be subject to the terms and conditions of the insurance policy. Further alleged that the insured requested for a cashless authorization for the treatment of Left Knee. On scrutiny of the cashless claim documents as provided by the insured, it was observed that the pre authorization form which is duly sealed and signed by the treating hospital the insured has undergone the procedure of robotic surgery. As per IRDA guidelines chapter V, all modern treatment shall be covered subject to sub limit on robotic surgeries. As the insured availed sum insured of Rs.3,00,000/- there is sub limit of Rs.75,000/- for the respective procedure. The amount of Rs.75,000/- was released for cashless in beginning followed by full and final payment Rs.67,500/- was settled (after deducting the hospital discount of Rs.7500/-) and paid directly to the hospital through NEFT dated 21.07.2022 by the answering Opposite Party. Further alleged that as per complaint total hospital bill was Rs.2,18,371/- and after cashless approval of Rs.75,000/- the remaining amount of Rs.1,43,371/- was paid by the insured to the hospital. Hence this complaint is for the amount of Rs.1,43,371/- spent by the insured on his knee treatment. As the maximum amount is already paid as per the sub limit prescribed under policy of insurance, there is no further amount available for payment under the policy. Further alleged that the cashless approval is given by the Opposite Party only on a preliminary evaluation of documents submitted by treating hospital/insured and it is subject to review upon the receipt of further details/documents from the insured patient or at any time. If amount of treatment is exceeding to cashless approval of cashless approval is denied then insured can submit his final claim for the reimbursement of the medical expenses incurred by him with the Opposite Party with all the required documents. Opposite Party’ company settles the claim according to terms and conditions of policy. The instant complaint is neither maintainable in law nor on facts. No deficient services have been rendered by the answering Opposite Party as alleged by the complainant. The complaint being pre-mature and false is not maintainable. The complainant has not come with clean hands. On merits, all other allegation made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. In order to prove his case, complainant tendered in evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C6.
5. To rebut the evidence of the complainant, Opposite party tendered in evidence affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1/A alongwith copies of documents Ex.OP1/1 to Ex.OP1/10.
6. We have heard the counsel for the parties and also gone through the documents placed on record.
7. The case of the complainant is that he purchased a Medi claim policy from Opposite Party valid for the period w.e.f 05.01.2022 to 04.01.2023 having sum insured of Rs.4,85,000/- for himself and for his wife. Unfortunately, during the policy period on 19.06.2022, the complainant got admitted in Hunjan Hospital, Ludhiana for his medical treatment, where he remained admitted upto 25.06.2022 and spent Rs.2,18,371/- on his treatment, but against the said amount Opposite Party only paid a sum of Rs.67,500/- to the treating hospital and refused to pay the remaining amount of Rs.1,43,371/-. So, in compelling circumstances, the complainant has to pay the remaining amount of Rs.1,43,371/- from his own pocket. On this, plea of the Opposite Party is that on scrutiny of cashless claim documents as provided by the complainant, it was observed that complainant has undergone the procedure of robotic surgery and as per the terms and conditions of the policy Ex.OP1/4, all modern treatment shall be covered subject to sub limit on robitic surgeries. As the complainant availed sum insured of Rs.3,00,000/- there is sub limit of Rs.75,000/- for the respective procedure. So, the amount of Rs.75,000/- was approved and from the aforesaid amount, an amount of Rs.7500/- was deducted as the same was discounted by the hospital and thereafter an amount of Rs.67,500/- was released to the complainant as full and final payment.
8. We have perused the document Ex.OP1/6, the perusal of the same shows that the Opposite Party already approved the amount of Rs.1,00,000/- on 17th June 2022, based on pre authorization request and other documents submitted i.e. before the hospitalization of the complainant. From the above, it appears that there is a contradiction in the plea taken by the Opposite Party. On the one hand, on the pre authorization request of the complainant, Opposite Party approved the amount of Rs.1,00,000/- and on the other hand, they are taking the plea that as the complainant availed sum insured of Rs.3,00,000/- and there is a sub limit of Rs.75,000/- and the complainant is entitled for Rs.75,000/- only.
10. In view of the above discussion, we are of the view that complainant is entitled for the amount of Rs.1,00,000/- as has already approved by the Opposite Party vide Ex.OP1/6. Out of which, an amount of Rs.75,000/- has already been paid by the Opposite Party, so now the complainant is entitled for remaining amount of Rs.25,000/- and we hereby allow the same.
11. Hence, we partly allow the complaint of the complainant and direct the Opposite Party to pay an amount of Rs.25,000/-(Rupees Twenty Five Thousand only) to the complainant. The compliance of the order be made by the Opposite Party within 30 days from the date of receipt of copy of the order, failing which, the Opposite Party is further burdened with Rs.5,000/-(Rupees Five Thousand only) to be paid to the complainant for non compliance of the order. Keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of costs. File be consigned to record room.
Announced on Open Commission
