SMT.MOLYKUTTY MATHEW : MEMBER
This is a complaint filed by the complainant U/S 35 of the Consumer Protection Act 2019 for an order directing the opposite party to pay an amount of Rs.10,318/- with interest on the basis of Star Health Medi classic Insurance policy along with Rs.50,000/- as compensation and cost to the complainant for the deficiency of service and unfair trade practice on his part.
The brief of the complaint:
The complainant had taken a policy of the OP on believing the assurance made by the agent of the OP, the policy with cashless facility and it will be very useful in future. The complainant had taken a policy (individual) covering the complainant and her husband for a period of 31/12/2019 to 30/12/2020 for Rs.1,50,000/- each vide policy No.P/181318/01/2020/005040 (customer ID No.13229650-2). The premium amount of the policy was Rs.11876/-. On April 2020 a pain was developed in left side ear of the complainant and she consulted a doctor in her locality and as per the advice of the doctor she was admitted in Indira Gandhi Co-operative Hospital,Thalassery on 4/5/2020 and discharged on 5/5/2020. At the time of admission the authorities send all the relevant documents to get the cashless facility. But one letter received from the OP to hospital authorities on 4/5/2020 rejecting the cashless facility to the complainant as per Star Health medi insurance by stating the reason that “As per the waiting period exclusion No.3 of the policy, the claim is not admissible for a period of 2 years from the date of inception of the 1st policy. So the hospital authorities told the complainant that she will not get cashless facility and she will have to pay money for treatment done by them. The complainant arranged the money with the help of relatives and friends. The complainant had paid an amount of Rs.10.318/- towards hospital expenses only. The act of OP in rejecting the cashless benefit and rejecting the entire claim caused heavy mental agony to the complainant . So there is deficiency of service and unfair trade practice on the part of OP. Hence the complaint.
After receiving the notice OP entered before the commission and filed his written version contending that the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc attached. Moreover as per the pre-medical examination as per reports it was revealed that the complainant was suffering from cardio related diseases. The OP had issued the policy after excluding treatment of diseases related to Cardio Vasular system for the 1st 4 years of the policy. The complainant has suffering otitis externa is a condition that causes inflammation of the external ear canal, which is the tube between the outer ear and eardrum. So the complainant had taken treatment for disease of ENT. All treatment of diseases related to ENT are excluded for a period of first 2 years as per waiting period IV II(A) of the policy. The company shall not believable to make payment under this policy if the hospitalization is directly or indirectly for the disease of ENT as per waiting period IV(II)(A) of the policy. Hence the OP has rejected the cashless policy and informed the same to the hospital and the complainant letter dated 4/5/2020. It is the settled law that the terms and condition of the policy and the OP’s side there is no deficiency of service or unfair trade practice and the complaint may be dismissed.
On the basis of the rival contentions by the pleadings the following issues were framed for consideration.
- Whether there is any deficiency of service on the part of the opposite party?
- Whether the complainant is entitled for any relief?
- Relief and cost.
The evidence consists of the oral testimony of PW 1 and Exts. A1 to A6 were marked. On OP’s side DW1 was examined and Exts.B1 to B5 marked.
Issue No.1:
The Complainant adduced evidence before the commission by submitting her chief affidavit in lieu of her chief examination to the tune of the pleadings in the complaint and denying the contentions in the version. She was cross examined as PW1 by the OP. The documents Exts.A1 to A6 marked on her part to substantiate her case. According to the complainant , she is the medical policy holder of OP and the agent of OP promised that the OP is providing policy with cashless facility also. But the OP rejected the claim. The complainant stated that she has taken this policy only to assure the cashless facility at the time of discharge. At the time of evidence PW1 states that “ നിങ്ങൾ discharge ചെയ്തതിനുശേഷം ആസ്പത്രി bill കൾ insurance company യ്ക്ക് അയച്ചു കൊടുത്തില്ലല്ലോ? ഇല്ല. രേഖകളെല്ലാം നേരിട്ട് കോടതിയിൽ ഹാജരാക്കുകയാണ് ചെയ്തത്. In re-examination PW1 also stated that ചികിത്സ സംബന്ധമായ bill കൾ ആരാണ് insurance company യ്ക്ക് അയച്ചുകൊടുക്കേണ്ടത് എന്നുപറഞ്ഞാൽ? ആശുപത്രിയാണ് അയച്ചുകൊടുക്കേണ്ടത് .But the hospital authorities not send the original medical bills to OP. So the complainant admitted in the hospital and discharged during the policy period and the medical expenses incurred for Rs.10,318/- shown in Et.A3(series) and Ext.A5. Since the OP denied the cashless benefit. So there is deficiency of service on his part.
The OP vehemently stated that there is no deficiency of service on his part. He relied upon Exts.B1 to B5 to substantiate his defense. On perusal of the pleadings, documents and evidence , we , he commission hold that the complainant is the star health medi classic insurance policy holder of OP and the insurance coverage from the period of 31/12/2019 to 30/12/2020. The complainant undergone treatment from 4//5/2020 to 5/5/2020 during the coverage period. So we are of the considered view that the OP is liable to pay the medical bill for Rs.10,318/- to complainant. But he failed to do so . So we hold that there is deficiency of service and unfair trade practice on the part of opposite party . Hence the issue No.1 found in favour of the complainant and answered accordingly.
Issue Nos.2&3:
As discussed above the complainant is the policy holder of Star health Medi classic insurance policy. The complainant is treated from 4/5/2020 to 5/5/2020 within the coverage period. So we hold that the OP is directly baud to redressal the grievance caused to the complainant. So the complainant is entitled to get the medical expenses from the OP. Therefore we hold that the opposite party is liable to pay the medical bill for Rs.10,318/- to the complainant along with Rs.6000/- as compensation and Rs.2000/- as litigation cost. Thus issue No.2&3 are also accordingly answered.
In the result the complaint is allowed in part directing the opposite party to pay the medical expenses Rs.10,318/- to the complainant along with Rs.6000/- as compensation and Rs.2000/- as litigation cost within 30 days of receipt of this order. In default the amount of Rs.10318/- carries 9% interest per annum from the date of order till realization. Failing which the complainant is at liberty to execute the order as per the provisions of Consumer Protection Act 2019.
Exts:
A1- Individual/Family ID card
A2-Rejection of authorization for cashless treatment
A3(series)-Medical bills
A4- Discharge summary dtd.5/5/2020
A5- Discharge bill
A6-Laboratory report
B1- Proposal form
B2-Insurance Policy
B3-Cashless treatment –pre-authorization request form
B4- Copy of rejection of cashless treatment
B5- letter of acceptance by the company dtd.3/1/2020
PW1-Lisy Thomas- complainant
DW1-Balu.M- OP
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
eva /Forwarded by Order/
ASSISTANT REGISTRAR
