By Sri. A.S. Subhagan, Member:
This is a complaint filed under section 35 of the Consumer Protection Act 2019.
2. Facts of the case in brief:- The Complainant and family is the beneficiary of insurance of Opposite Party as per policy No. P/18135/01/2020/006082 and wife of Complainant was undergone treatment and claim was lodged vide claim No.CIR/2021/181315/0500520 during the tenure of policy period from 18-03-2020 to 17-03-2021. The Opposite Party has offered either cashless treatment or entire reimbursement of hospital expenses to Complainant and it is also told by the Opposite Party that one day admission in the hospital is the eligibility for claim amount. On 03-12-2020, the wife of the Complainant met with an accident and got serious injuries on head that is Laceration over Right Eyebrow around 2CM in Size and Hemispheric Fissure (Maximum Thickness 5mm). The wife of Complainant was admitted in Assumption hospital, Sulthan Bathery on 03-12-2020 and referred to WIMS hospital Wayanad and admitted to Neuro ICU and the doctor advised for 3 months rest and advised to review in Neurosurgery OPD after one week and examined and treated the wife of Complainant as inpatient No.1P0001 and after one day treatment, and advised to consult with a neurologist and discharged the Complainant on 15-12-2020. The Complainant intimated the claim to Opposite Party immediately after the admission of wife; they registered the claim vide No.CIR/2021/181315/0500520 and the Opposite Party had offered cashless treatment, obtained all the original treatment records and medical bills and offered to settle the bill, but twisted from their offer and paid a part amount in hospital and remaining amount is remitted by the Complainant The Complainant spent an amount of Rs. 1,15,000/- for the treatment of his wife and the Complainant claimed the entire amount with the Opposite Party with medical bill of Rs.95,661/- but instead of giving the full amount the Opposite Party provided an amount of Rs.33,937/-. The Opposite Party has canvassed the Complainant by offering cashless treatments and easy processes and believing upon words of Opposite Party the Complainants had joined in Opposite Party’s health insurance policy with great hope, but the Opposite Party have committed unfair trade practices and willfully cheated the Complainant with evil motive. The Complainant is now convinced that the Opposite Party will not redress the grievance without recourse to legal steps. Therefore the Complainant prays the Commission to:
- Direct the Opposite Party to pay Rs.81,063/- as the hospital expenses
with 18% interest from the date of disbursing the amount ie.
15-12.2020 till realization of the amount.
- Direct the Opposite Party to pay an amount of Rs.25,000/- as
Compensation and
c) Direct the Opposite Party to pay Rs.10,000 /-as cost of this proceeding.
- To grant any other reliefs that the commission deems fit to grant.
3. The Opposite Party, upon getting summons from the Commission, appeared and filed version, the contents of which are as given below.
The Complainant had taken a Senior citizen red carpet Insurance Policy covering himself and his wife, Chinnamma Isaac for the period commencing from 18/03/2016 to 17/03/2017 and the same had been renewed upto 17/03/2022 for a sum insured of Rs.1,00,000/- each vide policy Number:P/181315/ 01/2021/008636. At the time of availing the policy, the Complainant was supplied with the Terms and Conditions of the policy. The terms and conditions of the Policy were explained to the Complainant at the time of proposing policy and the same was served to them along with the policy schedule. Moreover it is clearly stated in the policy schedule that “THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED”. It is submitted that in case of Senior Citizen Red Carpet Insurance Policy, medical examination is not required as the insured must be above 60 years of age. As per terms and conditions of the Senior citizen Red Carpet policy issued to the insured, only those Pre-existing diseases which are specifically declared by the proposer in the proposal form are covered under the policy. So it is compulsory that the information regarding the health must be provided in the proposal form for the insurer to provide coverage with suitable co-payment, ie, 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured. At the time of taking policy, the Complainant had disclosed that his wife was suffering from diabetes and hypertension in the proposal form and the same was endorsed in the policy schedule and the expenses relating to such diseases will be covered after 1 year from the date of inception of first policy with 50% co payment of each and every claim arising out of such pre-existing diseases. It is submitted that during the policy period of 2020-2021, (P/181315/01/2020/006082, the Opposite Party had received a request for cashless hospitalization from DM WIN4S Hospital, Wayanad stating that the Complainant’s wife, Mrs.Chirmamma Isaac was admitted at the hospital on 03/12/2020 with history of road traffic accident and was provisionally diagnosed with Traumatic brain injury. Based on the request and the records forwarded by the hospital, the Opposite Party has initially approved an amount of Rs.3500/- and informed the hospital vide letter dated 04/12/2020. Thereafter, the hospital has forwarded the discharge summary and bills of Rs.95,661/-. On verifying the discharge summary, it is seen that the patient was diagnosed with Moderate head injury, Diabetes Mellitus, Systemic Hypertension. Thus it is clear that the patient, Mrs. Chinnamma was also treated for diabetes mellitus and hypertension along with the injury sustained to her by accident. It is submitted that the coverage clause No: J of the 'Senior Citizen Red Carpet Insurance Policy’ reads as follows : “The policy is subject to copayment of 50% of each and every claim arising out of all pre-existing diseases and 30% of each and every claim for all other claims.” It is pertinent to note that under the coverage clause of the policy, the following would also apply viz,
A. Room Boarding, Nursing expenses all inclusive as provided by the
Nursing home/Hospital for sum insured of Rs.1,00,000/- is upto 1% of
the sum insured.
B. ICU charges for sum insured of Rs.1,00,000/- is UP to 2% of the sum
insured.
4. Based on the above limits and Co-pay, the claim amount has been arrived at
Rs.33937/- and the same was informed to the Complainant and the hospital vide letter dated 15/12/2020. The Complainant had only availed cashless facility and after discharged from the hospital, no original bills/documents were submitted before the Opposite Party for reimbursement as per the terms and conditions of the policy. The Opposite Party considered the admissible amount as per terms and conditions of the policy. As per the policy, the Opposite Party offers both cashless and reimbursement. The Opposite Party had processed the claim as per the terms and conditions of the policy and had approved the maximum amount which is payable as per the policy. The Opposite Party is not liable for any further amount. The Complainant after understanding the terms and conditions of the policy has been subscribing the same by paying the premium. The Opposite Party has not committed any unfair trade practice and cheated the Complainant. The Opposite Party had already approved the full admissible amount as per the terms and conditions of the policy. The Complainant is not entitled for any compensation and cost of the proceedings. The claim for compensation is unfounded and baseless and is only a figment of Complainant’s imagination to make illegal gains for himself. The Complainant is for the sole purpose of harassing the opposite parties with the intention for getting unlawful enrichment from the opposite parties who are dealing with public money and functioning under the guidelines of IRDAI controlled by the Government of India. As public money is held in trust, the company must exercise abundant caution in dealing with the claims by applying all conditions correctly. In view of the above facts and submissions prayed to dismiss the complaint.
5. The Complainant filed chief affidavit, Ext.A1 and A2 were marked by the Complainant and the Complainant was examined as PW1 on 13.04.2023. Chief affidavit was also filed by one Balu. M, Deputy Manager, Legal, Ext.B1 to B5 were marked from Opposite Party’s side and he was examined as OPW1.
6. On considering the complaint, version, affidavits and the Exhibits marked by both the parties to the complaint, oral evidences adduced and the facts and circumstances of the case, Commission raised the following points for consideration.
- Whether there has been any deficiency in service/unfair trade practice from the Opposite Party?
- If so, whether the Complainant is entitled to for compensation as prayed for?
- If so, whether the Complainant is entitled for cost of the complaint as prayed for?
- Any other relief?
7. Point No.1. :- The case of the Complainant is that though the Complainant
and his family were the beneficiaries of an insurance policy with the Opposite Party, the Opposite Party illegally sanctioned only a nominal amount towards treatment expenses, related to the treatment of the wife of the Complainant consequent to a read accident occurred to the Complainant’s wife, Chinnamma and thereby the Opposite Party committed unfair trade practice, for which they claim full amount of treatment expenses with interest, cost of the complaint and compensation etc.
8. On the other hand, the Opposite Party contents that they have paid the full eligible amount of claim in respect of the policy as per its terms and conditions.
9. In cross examination, the Complainant has stated that “ Hospital apJm-´n-c-ap-ff cashless claim application BWv \ÂIn-b-Xv. Discharge \v tijw insurance company bv¡v claim At]£ \ÂIn-bn-«n-Ô.
10. In cross examination, OPW1 has deposed that “R§Ä terms and conditions {]Im-c-ap-ff amount sImSp-¯n-«p-v. Claim reject sNbvXn-«n-Ô. “Ext.B4 {]Imcw 95,661/þ cq]-bmWv bill. R§Ä BsI sImSp-¯Xv 33,937/þ cq]-bm-Wv”.
11. From the deposition of the Complainant, it is seen that the Complainant has not submitted any claim application before the Opposite Party after discharge of his wife from the hospital. The Opposite Party has also deposed that they have not rejected the claim. In this circumstances, considering the deposition of the Complainant and the Opposite Party, for the time being we are not going to the merit of the case but is of the view to direct the Complainant to approach the Opposite Party with fresh application for claim under the policy for final settlement of the claim. As we have not gone to the merit of this case, the points raised are not answered here.
12. Hence, this complaint is disposed off directing the Complainant to approach the Opposite Party with fresh claim application and the Opposite Party is directed to consider and settle the claim application of the Complainant, as per law and terms and conditions of the policy, if he approaches them within a period of two months from the date of receipt of this order.
The Opposite Party is also directed to dispose such fresh claim application within three months of its submission by the Complainant.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 15th day of October 2024.
Date of filing:05.03.2022.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:
PW1. Issac. Complainant.
Witness for the Opposite Party:
OPW1. Balu. M. Deputy Manager, Legal.
Exhibits for the Complainant:
A1. Copy of Cashless Authorization Letter. dt:15.12.2020.
A2. Copy of Bill.
Exhibits for the Opposite Party:
B1. Copy of Letter. dt:16.03.2020.
B2. Copy of Request for Cashless Hospitalisation for Health Insurance.
B3. Copy of Cashless Authorization Letter. dt:04.12.2020.
B4. Copy of In-Patient Final Bill.
B5. Copy of Cashless Authorization Letter. dt:15.12.2020.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
