IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, ALAPPUZHA
Tuesday the 28thday of March, 2023.
Filed on 26.12.2022
Present
- Sri.S.Santhosh Kumar BSc.,LL.B (President )
- Smt.C.K.Lekhamma, B.A, LLB (Member)
CC/No.326/2022
between
Complainant:- Opposite party:-
Sri.Prasad T The Branch Manager
Rajapuram Star Health Insurance
Mangalam P.O. AN Puram, Alappuzha-688011
Thrikkunnappuzha-690515 (Adv.V.Pramod)
(Party in person)
O R D E R
SRI. S.SANTHOSH KUMAR (PRESIDENT)
Complaint filed u/s 35 of the Consumer Protection Act, 2019
1. Material averments briefly stated are as follows:-
Complainant availed an insurance policy from the opposite party on 6/7/2021 known as family health optima and it is being renewed every year. The 1st claim occurred with respect to the son of the complainant who is aged one year and nine months. Claim petition was filed on 3/12/2022 claiming an amount of Rs.13,728/- . The child was treated at M/s Believers Church Hospital, Thiruvalla. The total amount was Rs. 13,728/- out of which opposite party paid only Rs. 10,577/- after deducting Rs. 3151/-.
2. On enquirywith hospital it was revealed that opposite party used to deduct such amount from the bill and requested to file complaint before the Consumer Disputes Redressal Commission. Though complaints were made to the opposite party through letters and emails, there was no proper reply. Out of the total bill amount of Rs. 13,728/- only Rs. 10,577/- was allowed and they deducted an amount of Rs. 3151/- without satisfactory reason. Hence the complaint is filed for realizing an amount of Rs. 3151/- and Rs. 50,000/- as compensation on account of deficiency of service and unfair trade practice from the side of opposite party.
3. Opposite party filed a version mainly contenting as follows:-
The complaint is not maintainable either on facts or on law and it is liable to be dismissed. Complainant had taken a policy of health Insurance from the opposite party under the family health optima insurance plan on 6/7/2021 covering himself , wife and their son which has been renewed upto 5/7/2023 for a sum insured for Rs. 4 lakhs. At the time of availing the policy the complainant was supplied with the terms and conditions of the policy and it was explained.
4. Opposite party received a request for cashless treatment from M/s Believers Church Medical College Hospital, Thiruvalla stating that the son of the complainant baby Chethas Mahadevan was admitted in the hospital on 30 /11/2022 and was provisionally diagnosed with acute gastroenteritis. After receiving the cash less request form opposite party had initially authorized an amount of Rs. 5000/- and the same was informed to the hospital authority on 1/12/2022.
5. Thereafter the hospital had informed to the opposite party that the patient was discharged on 3/12/2022 and after the treatment the hospital authority had forward the discharge summary along with final bill amount of Rs. 15,886/-. This opposite party had processed the claim and found that the total payable amount is Rs. 10,577/- and was informed to the hospital authority vide letter dtd. 3/12/2022. Complainant has not approached the opposite party for reimbursement with balance paid receipts / documents till this date. As per condition no. 4 (c) and (e) of the policy.
6. As per condition no. 4 (2) (C) and (E) 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.
7. On receipt of notice from this Commission opposite party had again processed the claim and found that an amount of Rs. 2256/- is only liable to pay to the complainant. Complainant is entitled only for Rs. 2256/- as per the terms and conditions of the policy. There is no deficiency of service from the part of this opposite party since Rs. 10,577/- which was the admissible amount was paid on getting the bill from the hospital. Hence the complaint may be dismissed with cost.
8. On the above pleadings following points were raised for consideration
1. Whether there is any deficiency of service from the part of opposite party as alleged?
2. Whether the complainant is entitle to realize an amount of Rs. 3151/- being the balance of bill from the opposite party as prayed for?
3. Whether the complainant is entitled to realize an amount of Rs. 50,000/- as compensation from the opposite party as prayed for?
4. Reliefs and costs?
9. Evidence in this case consists of the oral evidence of PW1 and Ext.A1 to A4 from the side of the complainant . Opposite party has not adduced any oral evidence. Ext.B1 to B4 were marked.
10. Point No. 1 to 3
PW1 is the complainant. He filed an affidavit in tune with the complaint and marked Ext.A1 to A4.
11. PW1, the complainant had taken a medi claim policy known as Family Health Optima Insurance plan for himself and his family from the opposite party M/s Star Health & Allied Insurance Co. ltd.,on 6/7/2021 and it was renewed up to 5/7/2023. The sum assured was Rs. 4 lakhs. While so complainant’s son baby Chethas Mahadevan got admitted at M/s Believers Church Hospital, Thiruvalla on 30/11/2022 and discharged on 3/12/2022. A claim intimation was duly informed to the opposite party and they paid an amount of Rs. 5000/- as advance. The total bill amount was Rs. 13,728/-. Opposite party paid an additional amount of Rs. 5,577/- and hence a total amount of Rs. 10,577/- was allowed. In effect they had deducted an amount of Rs. 3151/-. Though complainant made several email correspondence with the opposite party the said amount was not allowed and hence the complaint is filed to realise the balance amount of Rs. 3151/- along with interest and Rs. 50,000/- as compensation. Opposite party filed a version admitting the policy. They also admitted that the total bill amount was Rs. 15886/- and after discount it was Rs. 13,728/- out of which they had paid an amount of Rs. 10,577/-. It was contended that as per condition No. 4(2) (C) & (E) of the policy the amount has to be claimed within 15 days and that certain amount such as admission charge, diet review and diet assessment, price of gloves, diaper etc are not admissible. After getting notice from this Commission they again processed the claim and found that an amount of Rs. 2,256/- is admissible. It was contended that since the original bills were not produced they did not pay the said amount and prayed for dismissal of the complaint. Complainant got examined as PW1 and marked Ext.A1 to A4. Opposite party did not adduce any oral evidence. Ext.B1 to B4 were marked from their side. Relying upon the evidence on record complainant who was appearing in person pointed out that he availed the mediclaim policy initially on 6/7/2021 and it was renewed periodically. On the date of admission of his son the policy was inforce. Though the matter was informed to the opposite party and they had only allowed an amount of Rs. 10,577/- and without any valid reason they deducted an amount of Rs. 3151/-. Complainant who is employed at Kerala University, Trivandrum is regularly appearing before this Commission on all posting dates after availing Casual Leave. It was pointed out that though Rs. 3151/- is a meager amount after issuing the policy opposite party deducted the same without any valid reason and hence the complaint may be allowed along with compensation. Per contra the learned counsel appearing for the opposite party pointed out that an amount of Rs. 5000/- was given initially on admission and on getting the bill balance amount of Rs.5577/- was also allowed. On their assessment Rs. 3151/- was not admissible as per the policy conditions. It was also pointed out that the bill was not produced within 15 days and they are not liable to pay any amount.However on getting notice from this commission they again processed the claim and found an amount of Rs. 2256/- is payable to the complainant. It was not paid since the bill was not produced.
12. The policy in this case is admitted. The opposite party also admitted that the son of PW1 got admitted on 30/11/2022 and discharged on 3/12/2022.When they got information regarding admission they paid an amount of Rs. 5000/- initially and Rs. 5577/- later. Admittedly the total bill amount is Rs. 15,886/- and after deducting discount it was Rs. 13, 728/-. Since opposite party paid an amount of Rs. 10,577/- the balance due is Rs. 3151/-. In the version opposite party admitted that when they re-processed the claim it was found that Rs. 2256/- is admissible. It was informed that Rs. 70/- being admission charges , Rs. 312/- being diet review and diet assessment charges, price paid for purchasing gloves, diaper etc are not admissible. Thus a total amount of Rs. 895/- is to be reduced and the balance admissible amount is Rs. 2256/-. Though in the version opposite party admitted that Rs. 2256/- is admissible they did not pay the amount and decided to contest the case for the best reason known to them. As stated earlier PW1 is employed with the Kerala University , Trivandrum. He is a native of Thrukkunnapuzha which is within the jurisdiction of this Commission and on a perusal of the proceedings paper it is seen that on all posting dates he was appearing. So it is seen that with much difficulty,after availing Casual Leave PW1 is attending the Commission. At the time of hearing PW1 was convinced that he is entitled only for Rs. 2256/-since certain amounts are non payable items. Hence PW1 is entitled to receive an amount of Rs. 2256/-.
13. As discussed earlier though the amount is meager it was contended by PW1 that he is availing the policy from 6/7/2021 and he renewed the same. The sum assured is Rs. 4 lakhs. The 1st claim came after one year and nine months. Though the total amount was Rs. 13,728/- only,opposite party did not paid the entire amount and initially deducted an amount of Rs. 3151/-. Though he made several email correspondents they were not ready to release the amount and finally when he filed this complaint they were ready to pay an amount of Rs. 2256/- after deducting the amount of non payable items. It is noticed that even the amount admitted in the version ie, Rs. 2256/- was not paid by the opposite party and for the best reason known to them they decided to contest the case. In said circumstances PW1 is entitled for compensation and we are limiting the same to Rs. 10,000/-. These points are found accordingly.
14. Point No. 4:-
In the result complaint is allowed in part.
a) Complainant is allowed to realize an amount of Rs. 2256/- along with interest @ of 9% per annum from the date of complaint ie, 26/12/2022 till realization from the opposite party.
b) Complainant is allowed to realise an amount of Rs. 10,000/- as compensation from the opposite party.
c) Complainant is allowed to realize an amount of Rs. 2000/- as cost from the opposite party.
The order shall be complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant, transcribed by him corrected by me and pronounced in open Commission on this the 28th day of March,2023.
Sd/-Sri.S.SanthoshKumar(President)
Sd/-Smt.C.K.Lekhamma (Member)
Appendix:-Evidence of the complainant:-
PW1 - Sri.Prasad T (Complainant)
Ext.A1 - Discharge summary
Ext.A2 - Copy of E-mail
Ext.A3 - Advance receipt
Ext.A4 - Copy of policy
Evidence of the opposite parties:
Ext.B1 - Copy of policy schedule and condition
Ext.B2 - Request form
Ext.B3 - Cashless authorization letter
Ext.B4 - Cashless authorization letter dtd.03.12.22
// True Copy //
To
Complainant/Oppo.party/S.F.
By Order
Assistant Registrar
Typed by:- Br/-
Compared by:-
