By. Smt. Bindu. R, President:

            This complaint is filed by Sajeev. C. V, Chenal House, Meenangadi, Wayanad against the Branch Manager, Star Health and Allied Insurance Company Limited, Branch Office, Sulthan Bathery as Opposite Party alleging deficiency of service and unfair trade practice from the side of the Opposite Party.

            2.  The Complainant states that the Complainant had availed an Insurance Policy for him and for his family under the family insurance scheme with Policy No.P/181315/01/2021/004888 on 10.11.2009 with the Opposite Party through their agent Sandeep. T and had remitted the premium without fail.  While so, the Complainant was affected by salivary stone and Dr. Manoj in ENT Super Speciality Institute and Research Centre advised him to undergo surgery to remove the stone.  Complainant further states that the Complainant had enquired with the Opposite Party office as to whether he will get the insured amount and after getting assurance that the amount will be disbursed by the Opposite Party, the Complainant had undergone the surgery.  According to the Complainant he had admitted in the hospital on 12.08.2021 and he had undergone surgery on 13.08.2021 and removed the salivary gland itself and he was discharged from the hospital on 14.08.2021 at about 4 pm.  The Complainant states that he had spent a total amount of Rs.1,35,000/- towards the hospital expenses but the Opposite Party granted only an amount of Rs.74,898/-.  The Complainant states that the Complainant is entitled to get an amount of Rs.60,102/- more which is incurred for the treatment and as per the policy terms which is denied by the Opposite Party and hence the complaint alleging deficiency of service and unfair trade practice from the side of the Opposite Party praying for a direction to the Opposite Party to release the balance amount of Rs.60,102/- and for other reliefs.

3.  Upon notice, the Opposite Party entered in to appearance and filed their version admitting the policy.  It is also admitted by the Opposite Party that the Complainant had undergone the treatment etc during the policy period from 11.11.2020 to 10.11.2021.  According to the Opposite Party, based on the terms and conditions of the policy, the Complainant is entitled to get a balance amount of Rs.22,039/- after deducting Rs.74,898/- which is already paid to the Complainant from a total admissible amount of Rs.96,937/-.  It is contented in the version that the Opposite Party is ready and willing to pay balance amount of Rs.22,039/-.  The Opposite Party also denied the assurance said to be given by the Opposite Party to the Complainant regarding the payment of full amount for treatment expenses. On the other hand the Complainant was informed that the payment will be subject to policy conditions.  According to Opposite Party, even though it is stated by the Complainant that he had incurred an amount of Rs.1,35,000/- as treatment expenses, the Opposite Party received the claim for Rs.1,00,819/- only.  It is also contented that the Opposite Party is not liable for payment of the expenses of bystander, travelling expenses and compensation.  The policy only covers the medical expenses and there is no deficiency of service or unfair trade practice from the side of the Opposite Party and prayed for dismissal of the complaint.

            4.  Evidence in this case consists of oral evidence of PW1 and Exts.A1 to A3 which were marked from the side of the Complainant.  From the side of Opposite Party, OPW1 was examined and Ext.B1 and B2 were marked.

            5.  Heard both sides and perused the records in detail along with facts and circumstances of the case.

            6.  The following are the main points to be analysed in this complaint to derive into an inference of the fact.

1. Whether the Complainant had sustained any loss, deficiency of service or unfair trade practice from the side of the Opposite Party?
2. If so, the quantum of compensation and costs to be awarded to the Complainant?

7.  In this case Ext.A1 is the Copy of Test Report of the Complainant and Ext.A2 is the Discharge Summary which shows that surgery was conducted on 13.08.2021 as alleged by the Complainant.  Ext.A3 is the Cash Bill issued by the Opposite Party for Rs.74,898/-.  Ext.B1 is the Copy of Policy Schedule and condition and Ext.B2 is the Bill Assessment Sheet.

8.  It is the specific case of the Complainant that during the life time of the policy, he had undergone a surgery by expending Rs.1,35,000/- but the Opposite Party had paid only Rs.74,898/- towards the claim amount.  During the cross-examination of PW1, the witness deposed that he is entitled to get Rs.3,000/- being the expenses incurred for bystander, Rs.2,000/- being the travelling expenses and Rs.25,000/- towards the loss sustained due to the removal of the gland.  It is admitted by the Complainant during cross-examination that Ext.B1 claim form is filed for Rs.1,00,219/-.  According to the Complainant the total expenses incurred for the treatment is Rs.1,35,000/- which is not supported by any evidence whereas Ext.B1 shows that the claim form is filed only for Rs.1,00,219/-.  Since the policy is admitted and the Opposite Party had released an amount of Rs.74,898/- to the Complainant, it is to be presumed that the Complainant is entitled to get the benefit under the policy.  Moreover it is admitted by the Opposite Party that they are ready to disburse the balance amount Rs.22,039/- after deducting the non-payable amount of Rs.3,882/-.  The Opposite Party has no case that the Complainant had refused to accept the admitted amount ie Rs.22,039/- when the same was offered to the Complainant.  During cross-examination OPW1 deposed that “t]mfnkn t\m¡nbm treatment \v GsXÃmw expenses A\phZn¡pw GsXÃmw A\phZn¡nà F¶v policy condition  ]dªn«p­v.  sImSp¡m³ hogv¨hcp¯nb kwJybv¡v ]eni sImSp¡Wsa¶v policy  ]dªn«p­v.  F{X iXam\amsW¶v ]dªn«nÃ.  Bank rate BWv F¶v ]dªn«p­v”.   OPW1 further deposed during cross-examination that there was no delay in filing the claim petition and the amounts deducted by the Opposite Party are not specifically stated in the policy conditions as deductions.  It is also admitted by the Opposite Party that they have no case that the surgery was not conducted and it is also admitted that after surgery the person needed the help of bystander to move on and has to depend vehicle for travelling.  According to OPW1, it is also not stated in the policy that bystander expenses and travelling expenses are excluded under the policy conditions but it is stated in the coverage portion.

8. Considering the entire evidences in toto, the Commission is of the opinion that the Complainant had proved Point No.1 in his favour and hence the following Orders are passed.

1. Since the claim is filed only for Rs.1,00,819/- the Opposite Party is directed to pay the balance amount of Rs.25,921/- to the Complainant with interest @ 8% per annum.
2. The Opposite Party is also directed to pay an amount of Rs.10,000/- (Rupees Ten Thousand Only) towards compensation and Rs.10,000/- (Rupees Ten Thousand Only) towards costs to the Complainant.

Needless to say that the above said amounts are to be paid within one month of the receipt of copy of this Order, otherwise the Opposite Party is liable to pay interest @ 8% per annum for the amounts awarded except that of costs from the date of order till date of realization.

Hence Consumer Case is partly allowed.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 23^rd day of January 2024.

Date of Filing:-11.03.2022.

PRESIDENT   : Sd/-

MEMBER       : Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              Sajeev. C. V.                                     Barber.

Witness for the Opposite Party:-

OPW1.          Balu. M.                                            Assistant Manager, Legal.

Exhibits for the Complainant:-

A1.                  Copy of Test Report.                                             Dt:05.08.2021.

A2.                  Copy of Discharge Summary.

A3.                  Copy of Cash Bill.                                                   

Exhibits for the Opposite Party:-

B1.                  Copy of Policy Schedule.

B2.                  Copy of Bill Assessment Sheet – Member Payment.                       

Dt:14.09.2021

PRESIDENT   :Sd/-

MEMBER       :Sd/-

/True Copy/

                                                                                                       Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-