By Sri. A.S. Subhagan, Member:

            The Complainant has filed this complaint under section 12 of the Consumer Protection Act 1986.

            2.  Facts of the complaint:-  The Complainant had taken a mediclaim policy from the 2^nd and 3^rd Opposite Parties through their agent Ms. Sobhana. N. K with agent code BA0000078377, the policy was named as “Senior Citizens Red Carpet Health Insurance Policy”.  Since 31.03.2019 to 31.03.2020, the policy number was P/181315/01/2019/005817 issued from the Sulthan Bathery branch of Opposite Party. During the Validity of the policy No.P/181315/01/2019/005817, the Complainant was admitted in SHRISHA Hospital, Pulpally, Wayanad District on 30.10.2019 with chest pain and cough. The Complainant had undergone treatment till 08.11.2019 with IP No.2019/524. The Complainant had paid an amount of Rs.12,910 /- towards the hospital expenses, which the Opposite Parties are liable to pay.  The Complainant on the day of admission itself, intimated the same to the office of the Opposite Parties, through their agent.  The Complainant, before discharge from the hospital, tried to contact the Opposite Parties to discuss the matter regarding the settlement of bill but they had not responded to it.  So, the Complainant had to pay it by himself. The Complainant later sent the claim form along with the medical bills to the office of the 2^nd  and 3^rd  Opposite Party through their agent above mentioned to get the amount reimbursed as per policy condition, that is 70% of the Hospital Bill would be assured. Thereafter, several times the Complainant approached the Opposite Parties for claim amount. After 62 days, the 2^nd and 3^rd Opposite Party had reimbursed an amount of Rs.5,124/- only through the bank account of the Complainant at Canara bank Pulpally branch. Even though the Complainant thereafter requested the Opposite Parties for the reimbursement of the balance amount of expenses incurred by him at the hospital, they did not respond to his request. The Complainant did not have any pre-existing disease at the time of inception of the policy and had continued with the policy without any break.  This act of the Opposite Parties amounts to deficiency in service and the Opposite Parties have committed breach of their service towards the Complainant. It is a shortcoming and deficiency in the service offered by the Opposite Parties for which the Complainant had to suffer severe mental pain and agony besides the inconveniences and loss. The act of Opposite Parties amount to unscrupulous exploitation of a consumer who had been a reputed policy holder. The act of the Opposite Parties had caused great inconveniences and hardship to the Complainant. The Opposite Parties are legally liable to pay compensation of Rs.10,000/- towards loss , damage and hardship caused to the Complainant.  The Opposite Parties are also liable to make good the loss and damages caused to the Complainant, besides repayment of the amount of Rs.7,786/-, the Hospital Bill.

            3.  On getting summons, the Opposite Parties appeared and filed joint version, the contents of which in brief are as follows:     It is submitted that the Complainant had taken a Senior Citizen Red Carpet Insurance Policy commencing from 31.03.2019 to 30.03.2020 for a sum insured of Rs.1,00,000/- vide Policy No.P/181315/01/2019/005817.  At the time of availing the policy, the Complainant was supplied with the terms and conditions of the policy.  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 along with the policy schedule.  Moreover, it is clearly stated in the policy schedule that “THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED”.  It is submitted that in case of Senior Citizen Red Carpet Insurance Policy, medical examination is not required as the entry age must be above 60 years of age. As per terms and conditions of the Senior citizen Red Carpet policy issued 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 Opposite Party 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.  It is submitted that the Complainant was admitted at Shrisha Hospital, Pulpally on 30.10.2019 and was diagnosed with Acute Bronchitis and after treatment the Complainant was discharged on 08.11.2019.  After discharged from the hospital, the Complainant had submitted claim form with discharge summary, bills of Rs.12,903/- and reports.  The 'Senior Citizen Red Carpet Insurance Policy’ Condition clause 5 reads as follows:- “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”.  It is pertinent to note that under the coverage clause of the policy, the following would also apply viz,

1. In respect of room, boarding and nursing expenses as provided by the hospital/ Nursing home at 1% of the sum insured subject to a maximum of Rs.1,000/- per day as the sum insured is Rs.1,00,000/-.
2. ICU charges up to 2% of the sum insured per day
3. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialist Fees (25% of sum insured per hospitalization) ie a maximum of Rs.50,000/- per hospitalization.
4. Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker and similar expenses (50% of the sum insured per hospitalization) ie a maximum of Rs.50,000/- per hospitalization.

4.  Based on the above limits the claim amount has been arrived.  The details are as follows:

Post Hospitalization Calculation Method:-

• 7% of the Hospitalization expenses are payable as post Hospitalization.
• Total payable Hospitalization amount (after applied 30% Co-payment (-) Room Rent + Nursing Charges (After applied 30% Co-payment) x 7%.
• Total payable hospitalization amount (after applied 30% Co-payment) : Rs.7,393/-
• Room Rent + Nursing Charges (After applying 30% Co-payment) Rs.3,780/-

Ie, Rs.7,393 – Rs.3,780 x 7% = Rs.3,613 x 7%= Rs.253/-

5.  Thus the Opposite Parties after applying the limits and co-payment as per terms and conditions of the policy had approved an amount of Rs.5,124/-.  It is submitted that the Opposite Party had processed the entire claim as per policy terms and conditions and has considered the standard payable amount at the time of reimbursement. But, after receipt of the complaint from this Hon’ble Forum, the Opposite Party again reprocessed the claim and considered the standard admissible amount and hence the Opposite Party is ready to give the balance amount of Rs.2,523/- to the Complainant. All other deductions were made as per policy terms and conditions. It is humbly submitted that even if this Hon’ble Forum finds any liability upon this Opposite Party, then the liability of the Opposite Party may be limited to Rs.2,523/-.  The Complainant is not entitled to any compensation or costs of the proceedings. The claim for compensation is unfounded and baseless and is only a figment of Complainant’: imagination to make illegal gains for him. No mental agony of whatever nature has been caused as the bill has been settled by the Opposite Party in time. The Complainant has no cause of action as there is no deficiency in service from the side of the Opposite Parties.

6.  The Complainant had no oral evidence.  No documents were marked from his side.  The Opposite Party filed chief affidavit and Exts.B1 to B4 were marked.  The Deputy Manager (Legal) of the Opposite Party Company was examined as OPW1 and heard both the sides on 03.08.2023.

7.  Considering the complaint, version and evidence brought upon before the Commission and the facts and circumstances of the case, Commission raised the following points.

1. Whether there has been any deficiency in service/unfair trade practice from the part of the Opposite Party?
2. If so, compensation and its quantum..?

8.  Point No.1:-  The policy is admitted by the Opposite Party.  But the case of the Complainant is that he had submitted claim application for reimbursement under the policy with all the documents claiming Rs.12,910/- while, the Opposite Party admitted and reimbursed a claim amount of only Rs.5,124/-.  This is deficiency in service/unfair trade practice from the part of the Opposite Party and hence he prayed to issue direction to the Opposite Party to reimburse the balance claim amount of Rs.7,782/- and to pay Rs.10,000/- towards compensation.  According to the Opposite Party, they had settled the claim paying Rs.5,124/-, the eligible claim amount as per the policy conditions under the policy to the Complainant.  In version, they stated that on reprocessing the claim after getting notice from this Commission, they have found that an additional amount of balance claim of Rs.2,523/- is due to the Complainant and submitted that they are ready to pay that amount to the Complainant.  A statement showing the calculation of amount of claim due to the Complainant is also given by the Opposite party in version which has not been challenged by the Complainant in evidence.  So, as to the calculation and arrival of the claim amount by the Opposite Party, Commission does not interfere.  But initially, the Opposite Party had admitted only Rs.5,124/- as the claim amount in place of the claim application for Rs.12,910/-. On getting notice from the Commission for appearance, they admitted that they are ready to pay Rs.2,523/- to the Complainant as additional amount.  From this, it is very clear that the Opposite Party was not willing to reimburse the total eligible amount of claim in good faith in the initial stage itself.  They admitted to pay additional amount of Rs.2,523/- only on filing the complaint before this Commission by the Complainant.  That is, if the Complainant had not filed this complaint before this Commission, the Opposite Party would be escaped from paying additional amount of Rs.2,523/- to the Complainant.  This unscrupulous act of the Opposite Party with evil intention is nothing but unfair trade practice/deficiency in service.  So, there has been deficiency in service /unfair trade practice from the part of the Opposite Party.  Therefore Point No.1 is proved against the Opposite Party.

8.  Point No.2:-  As Point No.1 is proved against the Opposite party, they are liable to reimburse the admitted amount of Rs.2,523/- and to pay compensation to the Complainant.

In the result, the complaint is partly allowed and the Opposite Parties directed to

1. Pay Rs.2,523/- (Rupees Two Thousand Five Hundred and Twenty Three Only) being the balance of admitted claim amount and
2. Pay Rs.8,000/- (Rupees Eight Thousand Only) as compensation for unfair trade practice/deficiency in service.

The above amounts shall be paid jointly and severally by the Opposite Parties to the Complainant within one month from the date of receipt of this Order, failing which the amount will carry interest @ 9% per annum from the date of this Order.

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 August 2023.

Date of Filing:-06.02.2020.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

APPENDIX.

Witness for the Complainant:-

Nil.

Witness for the Opposite Parties:-

OPW1.          Balu. M.                                Assistant Manager, Legal.

Exhibits for the Complainant:

Nil.                 

Exhibits for the Opposite Parties:-

B1.                  Copy of Policy Schedule and Conditions.

B2.                  Copy of Discharge Summary from Shrisha Hospital.

B3.                  Copy of Discharge Bill.                                                      Dt:08.11.2019.

B4.                  Copy of Bill Assessment Sheet –Member Payment. Dt:06.01.2020.      

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

/True Copy/

                                                                                                                Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-