Sri B.NARAYANAPPA,

      President

1. The complainant Sri. B.R. Vishwanatha, Mysore-560002 has filed this complaint against the opposite party The Manager, Star Health and Allied Insurance Company Ltd., Mysore praying to direct the opposite party to pay a sum of Rs.1,85,940/- being the difference of reimbursement of medical expenses to the complainant and compensation of
   Rs.10,000/- and cost of Rs.10,000/-.

2. The brief facts are that:-

The complainant being Senior Citizen and purchaser of  Senior Citizen Red Carpet mediclaim insurance policy No.P/141116/01/2018/007978 issued by the opposite party for an insured sum of Rs.3,00,000/- valid from 25.02.2018 to 14.02.2019 and paid a premium of Rs.15,222.  The complainant undergone a medical procedure of knee replacement surgery  in the Apollo BGS Hospital, Mysore on two occasions from 04.05.2018 to 06.05.2018 and  from 17.06.2018 to 28.06.2018 and incurred expenditure of Rs.51,343 and Rs.5,37,811/- respectively which were to have been reimbursed to him by the opposite party as per the terms of the medical insurance policy.  The opposite party paid to the Apollo BGS Hospital by way of authorized cashless treatment of Rs.26,342/- and Rs.1,23,658/- in respect of two medical expenses, as against Rs.51,343/- and Rs.5,37,811/- disallowing Rs.37,631/- and Rs.4,14,153/- the complainant paid Rs.4,51,784/- being the difference amount to Apollo BGS Hospital.  It is further case of the complainant that the opposite party is liable to pay to the Apollo BGS Hospital, Mysore in respect of two sums of Rs.35,940/- and Rs.3,00,000/- which is limit of the policy,  as per the terms of Red Carpet Senior Citizen mediclaim policy.  The act of the opposite party in making payments of Rs.26,342/- and Rs.1,23,658/- to the Apollo BGS Hospital, Mysore,  in place of Rs.35,940/- and Rs.3,00,000/- amounts to deficiency of service and unfair trade practice.  Therefore he contends that the opposite party is liable to pay a sum of Rs.1,85,940/- to complainant.

3. After registration of this complaint, notice was ordered to be issued to opposite party.  In response to notice the opposite party appeared through its counsel and has filed written version.  Admitting that after issuance of policy No.P/141116/01/2018/007978  to the complainant, the complainant underwent medical procedure of total knee replacement at Apollo BGS Hospital, Mysore and incurred expenditure of Rs.51,343/- and Rs.5,37,811/- on two occasions from 04.05.2018 to 06.05.2018 and 17.06.2018 to 28.06.2018 and further admitted that the opposite party paid to Apollo BGS Hospital authorized cashless treatment two sums of Rs.26,342/- and Rs.1,23,658/- and denies the allegations made by the complainant that the opposite party is liable to pay a sums of Rs.35,940/- and  Rs.3,00,000/- and further opposite party admits that on the basis of authorisation by the complainant to avail cashless facility an amount of Rs.26,342/- was settled to the treating hospital vide NEFT on 14.05.2018 and also an amount of Rs.1,23,658/- was settled to the treating hospital vide NEFT dated 12.07.2018 and submits that as per the coverage of the policy, the sub-limit for all major surgeries is limited to Rs.1,50,000/- per policy period for the insured having sum insured of Rs.3,00,000/- and denies all other allegations made in the remaining paragraphs of the complaint.

4. The complainant in support of his case has filed his affidavit by way of examination in chief and the same was taken as P.W.1 and produced certain documents.  On the other hand the opposite party has also filed its affidavit  by way of examination in chief and the same was taken as RW.1 and produced certain documents.

5. We have heard the arguments of both sides and both parties counsels have also filed their written arguments.

6. The points that would arise for our consideration are as under:-  

1. Whether the complainant proves that the act of non-payment of  difference of reimbursement of medical expenses of Rs.1,85,940/- to him by the  opposite party is amounts to deficiency in service and unfair trade practice?
2.  What order?

7.       Our findings on the aforesaid points are as follows:

       Point No.1 :- In the negative;

      Point No.2 :- As per final order for the following

:: R E A S O N S ::

8.        Point No.1:- The learned counsel for the complainant has vehemently argued and submitted that the complainant has obtained health insurance policy bearing No. No.P/141116/01/2018/007978  from the opposite party by paying  premium of Rs.15,222/- for an insured sum Rs.3,00,000/- valid from 25.02.2018 to 14.02.20196 and he further submits that the complainant undergone a medical procedure of knee replacement surgery in the Apollo BGS Hospital, Mysore  on two occasions from 04.05.2018 to 06.05.2018 and 17.06.2018 to 28.06.2018 and incurred expenditure of Rs.51,343/- and Rs.5,37,811/- respectively.  Out of which the Insurance company reimbursed Rs.26,342/- and Rs.1,23,658/-  to the Apollo BGS Hospital by way of authorized cashless treatment as against Rs.51,343/- and Rs.5,37,811/- disallowing Rs.37,631/- and Rs.4,14,153/- the complainant paid Rs.4,51,784/- being the difference amount to Apollo BGS Hospital.  The opposite party is liable to reimburse medical expenditure of Rs.3,35,940/-,  but out of which the opposite party reimbursed only Rs.26,342 + Rs.1,23,658/- and its due a sum of Rs.1,85,940/- to complainant.  Therefore the complainant sought relief of reimbursement of Rs.1,85,940/- from the opposite party. 

9. On the other hand, the learned opposite party counsel vehemently argued and submitted as per the contention taken in the version as well as in the affidavit of opposite party and as per the notes of arguments and specifically contended that opposite party the Star Health and Allied Insurance Company as per the terms and conditions of the policy issued by it to the complainant has  paid to Apollo BGS Hospital, Mysore authorized cashless treatment two sums of Rs.26,342/-  and Rs.1,23,658/- towards reimbursement of medical expenses as per terms and conditions of the policy issued to complainant by deducting some amounts and he further clearly stated that whatever the admissible amount as per the terms and conditions of the policy issued to complainant same has been settled by the opposite party to complainant.  Therefore the amount claimed by the complainant in the present complaint is not liable to be paid by the opposite party.  Hence, the opposite party counsel submitted that there is no merits in the complaint, hence, the same is liable to be dismissed.

10.  We have perused the copies of documents produced by the complainant such as legal notice, health insurance policy bearing No. No.P/141116/01/2018/007978  and the copy letter issued by Star Health and Allied Insurance Company- towards payment of Rs.26,342 + Rs.1,23,658/- to complainant.  and discharge summary issued by Apollo
    BGS Hospital, Mysore inpatient credit bill of Apollo BGS Hospital, Mysore etc.,.

11.  The opposite party has also produced documents such as proposal form of complainant and Star Health and Allied  Insurance Policy issued to complainant, discharge summary and bill assessment sheet and customer information sheet Senior Citizen Red Carpet Health Insurance policy mentioning the terms and conditions of policy issued to complainant.

12.  On carefully scrutinizing the complaint averments and affidavit of complainant and documents produced by the complainant as well as the version of opposite party and affidavit of opposite party and documents produced by opposite party and taking into consideration of the oral arguments as well as written arguments submitted by both the counsel appearing on behalf of both the parties and in view of the documentary evidence produced by opposite party regarding payment made by Star Health and Allied Insurance  Company of Rs.26,342/- + Rs.1,23,658/- to the complainant towards claim of the complainant in respect of medical reimbursement it appears that the Star Health and Allied Insurance Company i.e., the opposite party has properly paid to the Apollo BGS Hospital  by way of authorized cashless treatment of Rs.26,342/- + Rs.1,23,658/- respectively totally of Rs.1,50,000/- towards medical claim of complainant as admissible.  After statuary deductions as per the terms and conditions of the insurance policy issued to complainant by opposite party.  Therefore there is no merits in the complaint filed by the complainant.  Hence, we are of the opinion that there is no deficiency in service and unfair trade practice on the part of the opposite party  as alleged by the complainant.   Hence, we answer point No.1 in the negative.

13. Point No.2:- For the aforesaid reasons, we proceed to pass the following

:: ORDER ::

1. The complaint of the complainant is dismissed.
2. No order as to cost.
3. Furnish the copy of order to both the parties at free of cost.

(Dictated to the Stenographer transcribed, typed by her, corrected by us and then pronounced in open Forum on this the 30^th June, 2020)