BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 138 of 2021
Date of Institution : 26.07.2021
Date of Decision : 10.12.2024
Karnail Singh (aged 55 years) son of Sh. Mohar Singh, resident of village Chakarian (141), Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Ground Floor, Opp. Shakti Motors, Nr. IDBI Bank, Sirsa – 125055 (Haryana) through its Manager/ Incharge.
2. Star Health and Allied Insurance Company Ltd., 15, Shri Balaji Complex, 1st Floor, White Lane Royapettah, Chennai- 600014, through its Incharge (Authorized).
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA………MEMBER
Present: Sh. A. S. Wadhwa, Advocate for the complainant.
Sh. Ravinder Monga, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant and his wife Smt. Gurmeet Kaur had purchased Family Health Optima Insurance plan from ops vide policy No. P/211121/01/2018/001683 and further policy renewal endorsement no. P/211121/01/2019/002467 for a sum of Rs.ten lacs and bonus of Rs.2,50,000/- with effect from 25.09.2018 to 24.09.2019 and in the year 2017 complainant had paid total premium of Rs.25,158/- and further premium of Rs.25,158/- was paid by him. The complainant has been paying premium every year for renewal of policy and policy is continue since 2017. That in the month of October, 2020 wife of complainant suddenly fell ill and she was admitted to Fortis Hospital Ludhiana (Punjab) on 30.10.2020 for treatment and doctors advised her for surgery and as she had got surgery from that hospital. She had remained admitted in Fortis Hospital Ludhiana from 30.10.2020 to 15.11.2020 but unfortunately she could not be saved and died on 15.11.2020. It is further averred that during this period of admission, cashless facility was to be provided and the bill of Fortis Hospital Ludhiana was of Rs.8,83,233/- but ops paid only Rs.6,17,919/- to the hospital and remaining amount of Rs.2,65,314/- was paid by complainant from his pocket and apart from this an other bill/ memo no. 1339370 dated 04.11.2020 of Department of Pharmacy CMC Hospital, Ludhiana amounting to Rs.39,999/- was also paid by complainant to that hospital. At that time complainant was informed by ops’ employees that this remaining amount of Rs.2,65,314/- and Rs.39,999/- total Rs.3,05,313/- which were deducted by the company will be disbursed later on and because wife of complainant died and he was not in a position to agitate the above said deductions, the matter was kept open. It is further averred that thereafter ops refused to disburse the above said amount of Rs.3,05,313/- to the complainant without assigning any cogent reason and assigned a false reason orally that “this amount of deduction have not come into the claim” but have refused to give a written letter to the complainant and as such ops have caused deficiency in service and unnecessary harassment to the complainant. The complainant also got issued a legal notice dated 19.06.2021 to the ops but to no effect. Hence, this complaint.
3. On notice, ops appeared and filed written version raising certain preliminary objections. It is submitted that policy terms and conditions were explained to the complainant at the time of proposal. The complainant lodged the claim of his wife Smt. Gurmeet Kaur for her admission on 30.10.2020 and discharge on 15.11.2020 and requested for cashless authorization for treatment of Covid-19. After carefully analyzing the documents, medical treatment, bills etc. submitted being cashless documents, the claim of complainant was proceeded in accordance with terms and conditions of the policy and finally approved an amount of Rs.6,17,919/- and have been paid to the hospital through NEFT on 15.12.2020. Thereafter, the insured submitted another claim for reimbursement of Rs.74,739/- based on submitted claim documents. The claim was further proceeded and another amount of Rs.11333/- as per terms and conditions of the policy was approved and paid to insured through NEFT on 06.02.2021. Further more, on the request of complainant, the claim was renewed and considered for settlement of another Rs.3500/- and same was too paid to the insured through NEFT on 20.04.2021. The complainant was duly informed about the deduction of the amount being not payable and unproven treatment of Covid-19 being not covered under the terms and conditions of the policy as well as the bill dated 04.11.2020 has been submitting without mentioning the name of patient. In this manner, the claim lodged by complainant was Rs.9,23,232/- out of which the payable amount of Rs.6,17,919/- has already been paid after deducting the not payable amount on the basis of terms and conditions of the policy. It is further submitted that reason for deduction of Rs.3,05,313/- is as follow:
- As per the other excluded expenses No.190 of the policy, the charges pertaining to Glucometer forRs.3840/- are not payable.
- As per policy term and conditions, the charges for unproven treatment in management of Covid 19 for Immunocin (Rs.1,09,686/-), U Tryp (Rs.1,29,128/-) are not payable. (Arrange to file medical article towards the same).
- As per the other excluded expenses of the policy, the charges pertaining to gloves (No.181) for Rs.5726/-, Mask (No.183) for Rs.5672/-, Urometer (No.1940 for Rs.473/-, shoe cover (No.13) for Rs.1074/- filter for Rs.501/- and Caps (No.18) for Rs.432/-, Gamee Roller (No.89) for Rs.537/- are not payable. Hence, a total amount of Rs.14,415/- is not payable.
- As per the other excluded expenses of the policy, the charge towards the admission (Exclusion No.27) for Rs.680/-, TPA (No.178) for Rs.680/-, medical record (no.123) for Rs.255/-, dietician Rs.255/-, diet Rs.6375/- (No.158) are not payable. Hence, a total amount of Rs.8245/- are not payable, hence deducted.
- There is no patient name in bill dated 04.11.20 for Rs.39,999/- hence, the same was disallowed.
4. It is further submitted that hence the maximum payable amount of Rs.6,17,919/- is already paid to insured and now from the contents of complaint, it is clear that complainant has travelled beyond the terms and conditions of the policy which is not permissible under the law. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5.The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C5.
6.On the other hand, ops have tendered affidavit of Sh. P.C. Tripathy, Zonal Manager as Ex.R1 and documents Annexures R1 to R15.
7.We have heard learned counsel for the parties and have gone through the case file.
8.There is no dispute of the fact that complainant has been purchasing the health insurance policy for himself and his wife Smt. Gurmeet Kaur from ops since 2017 for the sum assured amount of Rs. ten lacs. The complainant is seeking reimbursement of the remaining amount of Rs.3,05,313/- regarding the policy commencing from 25.09.2020 to 24.09.2021 for the treatment of his wife Smt. Gurmeet Kaur insured from 30.10.2020 to 15.11.2020 as according to the complainant, total amount of Rs.9,23,232/- was spent on her treatment but ops have only paid/ reimbursed amount of Rs.6,17,919/-. On the other hand, ops have proved on record that they have already made payment of Rs.6,32,752/- and ops have duly explained the reason of deduction as mentioned above and as per terms and conditions of the policy. We are also of the considered view that ops have rightly reimbursed the amount of Rs.6,32,752/- because remaining amount was not payable as per list of excluded expenses given in Annexure R1 and as per terms and conditions of the policy and as bill of Rs.39,999/- dated 04.11.2020 was not having patient name which is also proved on record. The bill of Rs.39,959/- dated 04.11.2020 Ex.C5 is having no name of the patient and as such ops have not paid this amount to the complainant. So, the ops have reimbursed the above said amount of Rs.6,32,752/- as per terms and conditions of the policy and complainant is not entitled to any other amount from ops due to the reasons mentioned above by the ops as the amount of Rs.1,29,128/- was not payable because as per terms and conditions of the policy, the charges for unproven treatment in management of Covid 19 are not payable and the amounts for above said items and diet etc. are also not payable as per excluded expenses list.
9.In view of our above discussion, we do not find any merit in the present complaint and same is hereby dismissed but with no order as to costs. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 10.12.2024. District Consumer Disputes
Redressal Commission, Sirsa.
