Haryana

Karnal

CC/549/2023

Gobind Ram - Complainant(s)

Versus

The Branch Manager, Star Health & Allied Insurance Company Limited - Opp.Party(s)

V.K. Sharma

02 Sep 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.549 of 2023

                                                        Date of instt.03.10.2023

                                                        Date of Decision: 02.09.2024

 

Gobind Ram son of Shri Balwant Singh, resident of house no.309/10, near Sugni Devi School, Ladwa, District Kurukshetra.

 

                                                                        …….Complainant.

                                              Versus

 

1. The Branch Manager, Star Health and Allied Insurance Company Ltd. SCF-137, second Floor, above ICICI bank, Sector-13, Karnal.

 

2. The Managing Director, Star Health and Allied Insurance Company Ltd. New Tank Street, Valluvar Kottam, High Road, Nungambakkam, Chennai-600034.

 

                                                                  …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

 Argued by: Shri V.K. Sharma, counsel for the complainant.

                    Shri Naveen Khetarpal, counsel for the OPs.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased a cashless policy known as “Family Health Optima Insurance Plan” policy no.P/211114/01/2020/008087 in the month of November 2019, which was valid for a period of one year since 12.11.2019 to 11.11.2020. The basic sum assured was Rs.5.00 lacs with a recharge benefit of Rs.1,50,000/-. Under this policy, two persons, complainant and his wife covered for cashless treatment. Recharge benefit means that in case the basic amount insured is exhausted, then the payment will be made from the re-charge benefit amount. At the time of purchasing of the policy, the complainant completed all the requisite formalities as per the demand and directions of the OPs and filled the requisite insurance form and after their complete satisfaction, the OPs issued the abovesaid cashless policy. The said policy was got renewed every year and so is continued/effective till date. Its limited of coverage was gradually increased every year and in the year 2022, it was increased upto Rs.7,25,000/- besides a recharge benefit of Rs.1,50,000/-. In the month of June/July 2022, the wife of complainant namely Sawarnjeet developed pain in both of her knees which became severe with the passage of time. In the beginning, she could not walk upstairs but lateron she became helpless even to walk and so was completely confined to bed. On 30.08.2022, the complainant took his wife to Max Super Specialty Hospital, Mohali which is on the panel of OPs for the treatment of both knees and the concerned doctor after diagnose gave treatment and during treatment on 05.06.2023, concerned doctor came to the conclusion that there is no other alternative except to replace both knees and gave his opinion to get the replacement of knees.  After obtaining the opinion of concerned doctor of Max Super Specialty Hospital, Mohali, the complainant approached to the OPs and informed them that Max Super Specialty Hospital, Mohali has advised the wife of complainant for replacement of both knees, the complainant informed the OPs in this regard. The official of the OPs advised to seek second opinion form Guardian Hospital, Ambala-Jagadhari Road, Ambala Cantt. As per direction of the OPs, complainant went to said hospital and said hospital also suggested for replacement of both knees alongwith treatment of recently developed HTN Temporarily due to knee problem and stated that there is no other alternate, except to replace the knees. The complainant requested the OPs to direct the hospital authorities to give treatment on the basis of cashless policy but OPs have denied the treatment on cashless basis and thus, violated the terms and conditions of the policy. Under the compelling circumstances, the complainant got the replacement of both knees of his wife and has spent Rs.3,25,287/- on the treatment of his wife. Complainant  applied to the OPs for reimbursement of the abovesaid amount but OPs have sanctioned only Rs.1,28,000/-. The complainant requested the OPs several times to reimburse the entire amount but OPs have flatly refused to pay the balance amount and raised unnecessary objections. Then complainant sent an email to the Insurance Ombudsman but till today no action has been taken. As per terms and conditions, the OPs were bound and are liable to reimburse the entire treatment charges and the complainant is suffering a huge financial loss. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the insured Gobind Ram (Proposer) availed Family Health Optima Policy through Branch officer covering, Gobind Ram-self and Swaranjeet Spouse, for the sum insured Rs.5,00,000/-, vide policy no.P/211114/01/2023/010555, valid from 12.11.2022 to 11.11.2023. The terms and conditions were explained to the complainant at the time of proposing policy and same was served to the complainant alongwith policy schedule. The insured patient Swaranjeet was hospitalized at Guardian Hospital on 20.06.2023 to 27.06.2023 for the treatment of OA Knee. Based on the submitted reimbursement documents, the claim was processed and an amount of Rs.1,28,000/- was approved and paid to the insured on 05.08.2023 through NEFT-N217232580788274. The reason for the deductions during hospitalization period are:-

•  
•  

Hence, maximum payable Rs.1,28,000/- is already paid to insured and Rs.1,96,610/- is not payable. It is further pleaded that as per clause 5 “Loss Sharing-In case of a claim, this policy requires you to share the following costs: Expenses exceeding the followings sub limits: 4.20% of each and every claim as Co-payment.

“Co payment: Co payment means a cost sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified per centage of the admissible claims amount. A co-payment does not reduce the sum insured.”

As per coverage-clause no.AA –“Co payment (applicable for A to K and S). This policy is subject to co-payment to co-payment of 20% of each and every claim amount for fresh as well as renewal policies for insured persons whose age at the time of entry is 61 years and above.”

Also note that Reasonable and Customary charges: Reasonable and customary charges means the charges for service or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/injury involved. It is further pleaded that the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith policy schedule. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy alongwith terms and condition Ex.C1, copy of insurance policy from 12.11.2020 to 11.11.2021 Ex.C2, copy of insurance policy from 12.11.2021 to 11.11.2022 Ex.C3, copy of insurance policy from 12.11.2022 to 11.11.2023 Ex.C4, copy of prescription slips of Max Hospital dated 30.08.2022 and 05.06.2023 Ex.C5 and Ex.C6, copy of discharge summary of Guardian Hospital dated 27.06.2023 Ex.C7, copies of medical bills of Guardian Hospital Ex.C8 to Ex.C10, copy of claim form Ex.C11, copy of discharge voucher Ex.C12, copy of bill assessment sheet Ex.C13, copies of emails by complainant to OPs Ex.C14 and Ex.C15 and closed the evidence on 12.03.2024 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of proposal form Ex.R1, copy of policy schedule Ex.R2, copy of policy terms and conditions Ex.R3, copy of request for cashless hospitalization Ex.R4, copy of cashless denial letter dated 19.06.2023 Ex.R5, copy of claim form Ex.R6, copy of discharge summary of Guardian Hospital Ex.R7, copy of final bill of Guardian Hospital dated 27.06.2023 Ex.R8, copy of billing assessment sheet Ex.R9 and closed the evidence on 20.05.2024 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that the complainant purchased a cashless policy from the OPs  under the sum insured of Rs.5,00,000/-. During the subsistence of the insurance policy, wife of complainant got replaced her knees from Guardian Hospital, Ambala. Complainant spent Rs.3,25,287/- on the treatment of his wife, as the pre-authorization request was denied by the OPs. Complainant submitted the claim for reimbursement of said amount, but OPs paid only Rs.1,28,000/- and unnecessarily deducted the amount of Rs.1,96,610/- on the basis false and frivolous ground. Thus, there is deficiency in service and unfair trade practice on the part of the OPs  and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that the insured Swaranjeet was hospitalized at Guardian Hospital on 20.06.2023 to 27.06.2023 for the treatment of her knees. The claim was processed and as per terms and conditions of the insurance policy and an amount of Rs.1,28,000/- was approved and paid to the insured on 05.08.2023 and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant availed Health Insurance Policy Plan namely “Family Health Optima Insurance Plan” from the OPs. It is also admitted that during the subsistence of the insurance policy the wife of complainant has got replaced her knees from Guardian Hospital, Ambala and spent an amount of Rs.3,25,287/-. It is also admitted that an amount of Rs.1,28,000/- has already paid to the insured.

11.           Out of remaining amount of Rs.1,96,610/-, an amount of Rs.32,000/- has been deducted by the OPs on the ground of co-payment and an amount of Rs.1,64,610/- has been deducted on the ground of reasonable and customary charges.

12.           The Clause AA of the insurance policy Ex.R3/Ex.C1, is reproduced as under:-

“Co payment (applicable for A to K and S). This policy is subject to co-payment to co-payment of 20% of each and every claim amount for fresh as well as renewal policies for insured persons whose age at the time of entry is 61 years and above.”

13.           The OPs issued the insurance policy Ex.C2. On perusal of the said policy, the age of Swaranjeet is mentioned as 60 years. Hence, at the time of entering in the policy, the insured was below of 61 years. Thus, the deduction of Rs.32,000/- is not justified.

14.           Regarding deduction of Rs.1,64,000/- as “Reasonable and necessary charges.” The OPs have alleged that reasonable and customary charges means the charges for service or supplying, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/injury involved.

15.           OPs have failed to convince this Commission on what account of said deduction has been made in the claim. It appears that said deduction has been made by the OPs only on the basis of presumption and assumption, which is not admissible in the eyes of law.

16.           Furthermore, now a days it has become a trend of insurance companies, they issue the policies by giving false assurances and when insured amount is claimed, they make such type of excuses. Thus, the denial of the claim of complainant is arbitrary and unjustified. In this regard, we place reliance on the judgment of Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, wherein the Hon’ble Punjab and Haryana High Court has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

17.           Keeping in view, the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OPs while deducting the amount of Rs.1,96,610/- amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine one. Hence, the complainant is entitled for remaining amount of Rs.1,96,610/- alongwith interest, compensation for mental harassment and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.1,96,610/- (Rs. one lakh ninety six thousand six hundred ten only) to the complainant alongwith interest @ 9% per annum from the date of filing the complaint i.e.03.10.2023 till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs. 11,000/- towards the litigation expenses. This order shall be complied within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced
Dated:02.09.2024

         President,

      District Consumer Disputes                           

      Redressal Commission, Karnal.

 

                   ( Neeru Agarwal)            (Sarvjeet Kaur)

                          Member                        Member