Chandigarh

DF-II

CC/430/2018

Sanjay Kumar Srivastva - Complainant(s)

Versus

Star Health & Allied Insurance Company Limited - Opp.Party(s)

Adv. Nitin Sharma

14 May 2019

ORDER

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

 

Consumer Complaint  No	:	430 of 2018
Date  of  Institution	:	01.08.2018
Date   of   Decision	:	14.05.2019

 

 

 

 

Sanjay Kumar Srivastva, R/o #304, Phase-IV, Mohali, District SAS Nagar 160059 (Mohali)        

 

             ……..Complainant

 

Versus

 

1]  Star Health & Allied Insurance Company Limited, having Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai 600 034 through Signatory/Authorised Representative.

 

2]  Star Health & Allied Insurance Company Limited, having local office at SCO 130-131, 4^th Floor, Sector 34-A, Chandigarh 160035 through its authorised representative.

 

………. Opposite Parties

 

BEFORE:  SMT.PRITI MALHOTRA    PRESIDING MEMBER

            SH.RAVINDER SINGH     MEMBER

 

 

Argued By:       Sh.Nitin Sharma, Adv. for Complainant.

Sh.Gaurav Bhardwaj, Adv. for OPs.   

 

 

PER PRITI MALHOTRA, PRESIDING MEMBER

 

                                The case of the complainant in brief is that he availed Family Health Optima Insurance Policy from OPs effective from 29.2.2016 and got it renewed from time to time upto 28.2.2019 by paying timely premium.  It is averred that the said policy covers entire family of complainant comprising two adults and two children for Rs.3.00 lacs (Ann.c-1).  It is stated that unfortunately, the wife of complainant suffered pain in her left arm for which she visited PGIMER, Chandigarh on 31.3.2017 and after few number of visits, she was admitted therein on 20.9.2017 till 29.9.2017.  During her treatment, she underwent angiography and thereafter was operated for cardio and an amount of Rs.1,11,957/- has been incurred on the said treatment (Ann.C-2 colly). Afterwards, the complainant lodged reimbursement claim with Opposite Parties for Rs.1,11,957/-, but the OPs instead of paying the complete amount, paid only Rs.77,587/-.  The less payment of Rs.34,370/- done by the Opposite Parties on the ground that some medical drug and consumables are not included in the policy, has been agitated by the complainant with OPs, but they did not pay any heed nor made the payment.  Then a legal notice was sent to the Opposite Parties, but to no avail.  Hence, this complaint.

 

2]       The OPs have filed joint reply and while admitting the factual matrix of the case, stated that on scrutiny of the claim lodged by the complainant, it was found payable to the extent of Rs.77,587/- against the total bill submitted for Rs.1,09,777/- and the same was paid on 12.2.2018 through NEFT and deduction of Rs.32,190/- was made.  It is stated that the complainant was well aware that some of the expenses and items are in the exclusion list and the same shall not be paid by the Company.  It is submitted that the expenses towards mask, razor, cream, strips, electrodes, monitoring, filter, pack, cautery pad, duropore, gown, cotton, exam glove, hand rub, mouth wash, micropore, glass, bed pan, thermometer, vitamin K, for an amount of Rs.25,083/- were not payable. The charges towards diet & admission for Rs.365/-; expenses towards Ferritin, Vitamin, folate for Rs.450/-, the expense towards gloves for Rs.27/- and        pre-hospitalization expenses within 60 days before date of admission for Rs.6265/- are also not payable as per policy.  It is submitted that a total amount of Rs.32,190/- was rightfully deducted as per policy. Denying all other allegations and pleading no deficiency in service, the Opposite Parties have prayed for dismissal of the complaint.

 

3]       Replication has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the Opposite Parties in reply.

 

4]      Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       The issuance of the health insurance policy in favour of the complainant since the year 2013 and its renewal from time to time till 2019 is admitted. It is also admitted that the complainant lodged a claim with OPs for an amount of Rs.1,11,957/- on account of treatment taken by his wife. However, the complainant has challenged the less payment of claim i.e. Rs.34,370/- by the OPs against his total claim of Rs.1,11,957/-. 

 

7]       For the less settlement, the ld.Counsel for the OPs has submitted that the claim of the complainant has been settled on the basis of terms & conditions of the policy in question and the deductions were made under various heads as mentioned in Bill Assessment Sheet Ann.R-4. 

 

8]       The thorough perusal of the terms & conditions, so placed on record and keeping in view the policy coverage availed by the complainant since the year 2013, which was got renewed till the year 2019, it is made out that the deductions made from the claimed amount, have wrongly been done by the OPs.

 

9]       During the course of arguments, it was argued by the ld.Counsel for complainant that the deductions made under various heads as mentioned in Ann.R-1, are payable if the same are prescribed by the doctor.  The ld.Counsel for the OPs while refuting this contention, stated that the items are not so prescribed on the letter head of the doctor concerned, so they are not payable.

 

10]      We are not convinced with the explanation submitted by the ld.Counsel for OPs, as all the items, as required to perform a particular procedure/surgery by the doctor, no separate prescription is ever given in routine course and are presumed to be prescribed.  Hence, the deductions made by the OPs out of the total claim amount of the complainant, are wrong & illegal, which amounts to deficiency in service.  The complainant is fully entitled for the complete claim amount without any deductions. 

 

11]     From the above discussion & findings, as made in the preceding paragraphs, the present complaint is allowed with directions to the Opposite Parties No.1 & 2 to reimburse the balance amount of Rs.34,370/- to the complainant. The OPs No.1 & 2 are also directed to pay compository cost of Rs.8,000/- for causing harassment to him due to their deficient act and for litigation expenses.

         This order shall be complied with by the OPs within a period of 30 days from the date of receipt of copy of this order, failing which they shall be liable to pay additional compensatory cost of Rs.5,000/- apart from the above relief.  

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

14^th May, 2019                                                                        Sd/-  

                                                                    (PRITI MALHOTRA)

PRESIDING MEMBER

 

 

Sd/-

(RAVINDER SINGH)

MEMBER