SMT. RAVI SUSHA  : PRESIDENT

         This complaint has been   filed by the complainant under sec.35 of the Consumer Protection Act 2019 seeking to  get an order directing opposite party to  refund the balance inpatient bill  ie Rs.73641/- with 9% interest  and also Rs.50,000/- towards compensation and  litigation cost alleging deficiency in service on the part of OP.

  Briefly stated  the complaint that ,the complainant had taken  a health policy  of OP from 2016 and renewed  it  upto  date and  his  health  insurance policy  having  one year coverage  from 8/3/2022 to 7/3/2023 for an amount of Rs.2,00,000/-and Rs.19,956/- as premium. The complainant submits that he  has sustained a stroke and   was admitted  and treated at Kannur Sreechand Hospital from 6/8/2022 to 16/8/2022 as an  inpatient  and total inpatient bill was Rs.124340/- and that OP had given Rs.50699/- out of total inpatient bill of  Rs.124340/- and the balance amount  of Rs.73641/- was paid by the complainant at the time of discharge.  The authorization letter sent by the  son of the complainant  that of Rs.50,699/- is not accepted.  The OP has to pay the total discharge bill.  Complainant  alleged that there is dereliction of good service  to the complainant.  The OP has committed gross deficiency of service and  unfair trade practice.  Hence this complaint.

      After receiving notice, OP  resisted the claim of the complainant through this complaint and  filed  version stating that the complainant  had taken  health insurance under the Senior citizen Red carpet insurance policy from OP on 8/3/2016 covering himself and his wife and the same has been renewed  upto 7/3/2023 for a sum insured of Rs.2,00,000/- each.  At the time of availing  the policy  the complainant was supplied with the terms and conditions.   According to OP, the insurance  under this policy is subject to conditions, clauses, warranties, exclusions, etc attached. Further states that as per terms and conditions of the Senior Citizens red carpet policy  to the complainant  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 OP 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. After receiving the cashless request form, the  company had initially authorized an amount of Rs.2,00,000/- and the same was informed to the hospital authority on 11/8/22.  Thereafter the hospital had informed to the OP that the complainant was discharged on 16/8/2021 and  after the treatment, the hospital authority had forwarded the discharge summary along with final bill amount of Rs.1,24,340/-. As per the terms and conditions  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  admissible claim for   all other claims for a sum insured of Rs.1,00,000/- to Rs.10,00,000/-.  In respect of room, boarding and nursing expenses as provided by the hospital/nursing home at 1% of the sum insured ie Rs.1000/- per day as the sum insured is Rs.1,00,000/-.  Based on the above mentioned terms and conditions of the policy, the OP had processed the claim and enhanced the amount  to Rs.30,699/- and the same was informed to the hospital authority on 16/8/2022.  Thus the total amount approved by the OP will comes to Rs.50699/-.  OP further submitted that as per the condition No.5( c)&(E) of the policy the claim must be filed within 15 days  from the date of discharge from the hospital and the insured person shall obtain and furnish the  company  with all original bills receipts and other documents upon which a claim is based and on receipt of the notice the OP had again processed the claim and  found that  Rs.1912/- is only liable to  pay the complainant.  The OP had acted as per the  terms and conditions of the policy.  There is no deficiency in service r unfair trade practice on their part.  Hence prayed for dismissal of this complaint.  

       At the evidence stage, complainant  filed  chief affidavit and documents. Examined as PW1, and the documents got marked Exts.A1 to A6.  On the side of OP, Deputy Manager(legal) of OP filed his proof affidavit and examined as  DW1.  Marked Exts.B1 to B5.

   After that  the learned counsel  of both parties made argument .

   According to OP, the insurance  under this policy is subject to conditions, clauses, warranties, exclusions, etc attached with policy. Further states that as per terms and conditions of the Senior Citizens red carpet policy  to the complainant  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 OP 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.

   Here during cross-examination, PW1 categorically deposed that  “policy കിട്ടിയതിനുശേഷം നിങ്ങൾക്ക് policy യെ ക്കുറിച്ച് വല്ല ആക്ഷേപവും ഉണ്ടായിരുന്നോ? ഇല്ല Terms and condition-നും തന്നിരുന്നോ? തന്നിരുന്നു. Document ഹാജരാക്കിയിരുന്നു.  Terms and condition നിങ്ങൾ വായിച്ചു മനസ്സിലാക്കിയിരുന്നു? അതെ. Senior Citizens red carpet policy  ആണ്? അതെ”.

    The policy certificate is marked as Ext.A1 and OP has produced policy  with schedule marked as Ext.B1. In Ext.A1, it is specifically mentioned that co-payment:- For sum insured options upto Rs.10,00,000/- co-pay for PED claims:50% , co-pay for  Non PED claims: 30% irrespective of sum insured.

 Here there is no dispute that the insured has sustained a stroke and   was admitted  and treated at Kannur Sreechand Hospital from 6/8/2022 to 16/8/2022 as an  inpatient  and total inpatient bill was Rs.124340/-.  It is also a fact that OP had given Rs.50699/- out of Rs.124340/- and the balance amount  of Rs.73641/- was paid by the complainant.

According to OP as per the calculation after deducting non-payable items from the total inpatient  bill, complainant is eligible to get Rs.75159/- and after deducting 30% co-payment, he is entitled to get only Rs.52611/-.  Out of which Rs.50699/- was given.  So according to OP, complainant is entitled to get balance amount of Rs.1912/- and they are ready to pay the said amount to the complainant.

   This table submitted by the OP, in their version, has not been given to the complainant along with policy terms and conditions.  During cross-examination PW1 denied the knowledge of the table as scheduled by the OP.  As far as complainant is concerned  he is entitled to get the grand total of inpatient bill subject to co-payment.  As per Ext.A3 inpatient bill the amount is Rs.124340.00/-.  As per the policy condition in Ext.A1, the co-payment is 30% of the  bill amount. Ie Rs.37301/-.  So the OP is liable to pay the balance amount to the insured complainant ie Rs.87038/-.  Out of which OP had paid Rs.50699/- to the complainant.  The balance amount to be paid by OP as per Ext.A1 policy condition is Rs.36339/-.  So the complainant is entitled to get that much amount.

   Since OP had not paid the entire amount as per the policy, there is deficiency in service on the part of OP.

       In the result, complaint is allowed in part.  Opposite party is directed to pay Rs.36339/- with 4% interest to the complainant from the  date of complaint till realization.  Opposite party is further directed to pay Rs 10,000/- towards compensation  and Rs.5000/- towards cost of the proceedings to the complainant. Opposite party  shall comply the order within one month from the date of receipt of this order.  Failing which the awarded amount  except  cost carries 9% interest from the date of complainant till realization.  Complainant can execute the order  as per provision of Consumer Protection Act 2019.  

Exts:

A1-Policy dtd.8/2/22

A2- settlement cash receipt dtd.16//8/22

A3- Inpatient bill dtd.16/8/23

A4-Copy of lawyer notice 21/10/22

A5-postal receipt

A6-Acknowledgment card

B1-copy of policy schedule

B2-copy of  request for cashless hospitalization

B3- copy of cashless authorization letter dtd.11//8/22

B4-copy of discharge summary and bills

B5- copy of cashless authorization letter dtd.16/8/22

PW1-Michael.K.T- complainant

DW1-Balu.M-OP

Sd/                                                   Sd/                                                     Sd/

PRESIDENT                                             MEMBER                                               MEMBER

Ravi Susha                                       Molykutty Mathew                                    Sajeesh K.P

eva           

                                                                        /Forwarded by Order/

                                                                   ASSISTANT REGISTRAR