By. Smt. Beena. M, Member:
The Complaint is filed under section 12 of the Consumer Protection Act, 1986.
2. Brief facts of the case are given below:
The case of the Complainant is that the Opposite Party is engaged in the service of Medical Insurance and the Complainant has joined in the Family Optima Insurance Policy bearing No.P/181318/01/2017/003490 from the Opposite Party for the period from 02.02.2017 to 01.02.2018 and the policy had the coverage of the Complainant as well as the other family members including his wife and 3 children. During the validity period of the policy due to Multi Nodular Goitre non-toxic, the wife of the Complainant had undergone treatment for thyroidectomy on 06-09-2017 and she was admitted in the hospital for surgery and the same was intimated to the Opposite Party and surgery was conducted on 06.09.2017 and discharged there from on 08.09.2017. The Complainant has incurred an amount of Rs.1,16,750/-towards treatment expenses. After discharge, the Complainant submitted claim form to the Opposite Party. The Opposite Party without any basis or criteria had granted Rs.76,164/- and denied the balance claim of Rs.40,586/-. Thereafter, the Complainant approached with a review application and made several attempts to get the balance amount. However the Opposite Party was not prepared to reconsider the claim of the Complainant, finally the Complainant sent a lawyer notice demanding the amount. After receiving the notice the Opposite Party sent a reply stating baseless reasons. The act of the Opposite Party is deficiency in service and due to that the Complainant had caused mental agony, financial loss, time loss, and troubles. Hence the Complainant filed the complaint for getting the balance amount of claim outstanding, compensation of Rs.50,000/- from the Opposite Party and cost of the complaint.
3. The Opposite Party entered appearance through their Advocate, filed written version and contested the case. The Opposite Party stated that the Complainant had filed the petition only to harass and vex the Opposite Party. The Opposite Party further averred that at the time of issuance of the policy the Opposite Party had explained and supplied the terms and conditions of the policy. It is clearly stated in the policy schedule “THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED’’. The recital of the policy issued to the Complainant clearly reveals that if during the period stated in the Schedule the insured person shall contract any disease or suffer from any illness or sustain bodily injury through accident and if such disease or injury shall require the insured person upon the advice of a duly Qualified Physician/Medical Specialist/Medical practitioner or of duly qualified surgeon to incur hospital in India as an in-patient, the company will pay to the insured person the amount of such expenses as are reasonably and necessarily incurred up-to the limits indicated. The coverage clause of the policy issued to the Complainant clearly reveals that Room, Boarding, Nursing expenses as provided by the hospital/Nursing home as per class cities basis. In the instant case the present hospital was situated in Calicut district and it comes under “Other Locations” Categories. As per terms and conditions of the policy, Other Locations means Rest of India not falling under Class A and Class B. ie, 1% of the sum insured subject to maximum of Rs.2000/- per day is applicable to Room, Boarding and Nursing expenses. The Opposite Party has allowed the full admissible claim amount as per the policy conditions in time. There has been no delay, negligence or default or latches in processing the claim of the Complainant for effecting payment of the amount legally due to him. The Opposite Party further denied the allegations that the Opposite Party had not disclosed any such terms and conditions which will entitle them for any deductions from the claim amount at the time of joining policy. So, the Opposite Party prayed for dismissal of the complaint with compensatory costs.
4. On perusal of complaint, version, and documents, the Commission raised the following points for consideration:-
- Whether there is any deficiency of services or unfair trade practice happened from the part of Opposite Parties?
- Whether the Complainant is entitled to get any relieves as prayed for?
- Whether the Complainant is entitled to get compensation and what order as to cost.
5. Point No. 1 to 3 :- For the sake of convenience and brevity all points are considered together.
6. The Complainant was examined as PW1 and the documents produced were marked as Ext.A1 to A4. OPW1, Mr. Balu was examined from the side of the Opposite Party and Ext.B1 to B3 were marked. (B1 marked with objection). Ext.A1 is the health insurance policy of the Complainant, Ext.A2 is the photo copy of the discharge summary, Ext.A3 series is the copy of lawyer notice with postal notice and A/D card and Ext.A4 is the reply notice. Ext.B1 is the copy of policy schedule for the period from 02.02.2017 to 01.02.2018, Ext.B2 is the copy of discharge summary and Ext.B3 is the copy of bill assessment sheet - member payment issued by the Star Health and Allied Insurance Company Limited.
7. The case of the Complainant is that the full claim amount was not paid to the Complainant as per the policy. It is undisputed that the Complainant purchased a health insurance policy bearing No.P/181318/01/2017/003490 for himself and his family members for the period from 02.02.2017 to 01.02.2018. The Opposite Party clearly clarified the reason for the non-payment of the full claim amount through their version and evidence. It is a well-known fact that there are certain terms and conditions for any type of policy. It is clear from the documents presented by the Complainant and the documents produced by the Opposite Party that the policy taken by the Complainant was in the name of Family Optima Health Insurance. On the reverse side of the Ext.A1, it is clearly mentioned that the policy along with printed terms and conditions supplied. However, the Complainant not produced the document containing the terms and conditions. There can be no policy without policy conditions and terms. There is no case where the Complainant did not receive any money from the Opposite Party. The only grievance is that the full amount claimed has not been allowed. The reason for the deduction of the amount has been clearly and satisfactorily stated by the Opposing Party. On perusal of Bill Assessment Sheet, it reveals that Complainant has claimed an amount of Rs.1,16,750/- but after deduction amount payable is shown as Rs.76,165/-. The Opposite Party deducted Rs.40,586/- towards reasonable deduction, it is clear in the Assessment Report that what are the reasonable deduction. So, this Commission is of the view that Complainant is not entitled to full reimbursement of his bill. There is no case in the complaint that the Complainant did not receive the document containing the terms and conditions. It is not possible to believe that there can be any policy without terms and conditions and it is the responsibility of the Proposer to read and understand the forms and terms and conditions of the policy, before signing the same. If the Proposer disagree with the terms and conditions of the policy he may return the policy stating reasons for his objection within free look period. In these circumstances, based on the available documents and arguments, this Commission finds that the arguments of the Opposite Party can be believable. From the available materials and documents, it is evaluated that the arguments raised by the Complainant are not correct and that the money entitled to be sanctioned under the policy has been paid. In our opinion, there is no unfair trade practice on the part of the Opposite Party for intimating such information containing the specific clause of the policy terms and conditions. So we are of the view that the Complainants are not entitled to get any relief against the Opposite Party. There is no merit in the present Complaint.
In the result, the complaint is dismissed without cost.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Commission on this the 20th day of May 2022.
Date of Filing: 17.08.2018.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
APPENDIX.
Witness for the Complainant:-
PW1. Haris. Business.
Witness for the Opposite Party:-
OPW1. Balu. M. Assistant Manager.
Exhibits for the Complainant:
A1. Family Health Optima Insurance Plan for the period of 02.02.2017
to 01.02.2018.
A2. Discharge Summary from Baby Memorial Hospital, Kozhikode.
Dt:08.09.2017.
A3(a). Copy of Lawyer Notice. Dt:05.05.2018.
A3(b). Acknowledgement Card.
A4. Reply Notice. Dt:01.06.2018.
Exhibits for the Opposite Party:-
B1. Copy of Family Health Optima Insurance Plan for the period of
02.02.2017 to 01.02.2018.
B2. Copy of Discharge Summary. Dt:08.09.2017.
B3. Copy of Bill Assessment Sheet – Member Payment.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR
CDRC, WAYANAD.
