Sri B.NARAYANAPPA,

      President

1. The complainant Sri. D.R. Anantharam Mysore-5600265 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.84,699/- being the reimbursement amount denied to him  with interest @ 12% p.a. and to pay a sum of Rs.5,000/- towards cost and Rs.10,000/- towards compensation.

2. The brief facts are that:-

 The opposite party is a body corporate incorporated under the Indian Companies Act, 1965 with its registered office at #1, New Tank Street,, Valluvar Kottam High road, Nungambakkam, Chennai-600034, having its branches all over India.  The opposite party is one such branch at Mysore.  The complainant is the insured person with the opposite party and obtained health policy bearing No.P/141116/012018/004368 dated 11.09.2017 for Rs.10,00,000/- issued by the opposite party valid from  11.09.2017 to 10.09.2018 and paid a premium of Rs.6,706/-.  The policy issued by the opposite party to complainant is health/mediclaim policy.  The complainant being the policy holder/beneficiary is assured reimbursement of medical expenses by the opposite party over and above a basic sum of Rs.3,00,000/-  mentioned above is to be and being covered by the mediclaim policy purchased by the complainant from Reliance General Insurance Company which bears the number 1403272825000309 dated 27.03.2017.  As such the Reliance General Insurance company liable to pay basic and initial sum of Rs.3,00,000/- only in terms of combined effect of the above two health insurance policies which the complainant has obtained from Reliance Insurance Company and opposite party.

3. It is further case of the complainant that he went through the knee replacement surgery at Prashanth Superspeciality Hospital, Chennai and incurred hospitalization medical expenditure of Rs.4,43,660/- and also Rs.6,400/- only in respect of the above said knee replacement procedure and a post-hospitalization medical expenditure of Rs.3,227/-.  Both of which are reimbursable in terms of the above two mediclaim insurance policies.  A total sum of Rs.4,53,827/- medical expenditure was incurred by the complainant in respect of said knee replacement surgery at Chennai.    It is further case of the complainant that the Reliance General Insurance Company reimbursed to the above said  Prashanth Superspeciality Hospital an amount of Rs.3,00,000/- only on account of the mediclaim insurance policy and the complainant paid balance amount of Rs.1,43,660/- in cash.  The claim of the complainant to opposite party  for the reimbursement of his medical expenses of Rs.1,53,287/- shall be paid by the opposite party in terms of the extension health policy.  But the opposite party reimbursed only Rs.68,599/- and the opposite party is due in sum of Rs.84,688/- the opposite party has unlawfully withheld the reimbursement of Rs.84,688/- to the complainant which act of the opposite party amounts to deficiency in service and unfair trade practice.  Therefore the complainant has come up with this present complaint.

4.  After registration of this complaint, notice was ordered to be issued to opposite party.  In response to notice he appeared through his counsel and has filed version.  Admitting the averments made in para 3 and 4 of the complaint i.e., issuance of policy No.P/141116/012018/004368  dated 11.09.2017 in favour of the complainant and issuance of policy to the complainant by the Reliance General Insurance company bearing No.1403272825000309 dated 27.03.2017 and the liability of Reliance General Insurance Company to an extent of Rs.3,00,000/- only and also partly admitting the averments made in the para 5 of the complaint regarding hospitalization medical expenditure incurred by the complainant and denied the rest of the averments made in the remaining paragraphs of the complaint and admitted that the complainant/insured was inpatient hospitalized on 14.02.2018 in Prashanth Superspeciality Hospital Chennai and discharged on 21.02.2018 and submitted that the opposite party settled reimbursement of medical expenditure claimed by the complainant to an extent of Rs.68,599/- vide cheque No.613041 dated 07.04.2018 and also once again reviewed and settled an amount of Rs.6,150/- vide cheque No.655100 dated 06.09.2018 and further submitted that an amount of Rs.3,00,000/- was settled to the insured by  other TPA and the opposite party further contended that as per the terms and conditions of the mediclaim policy issued to  complainant  a total amount of Rs.3,74,749/- was settled to complainant out of total claim amount of Rs.4,47,037/-.  Therefore there is no liability on the part of opposite party for payment of money as claimed by the complainant in the complaint.  Hence, prays to dismiss the complaint.

5. 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 his affidavit reiterating and reaffirming the contents of its version and produced certain documents.  

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

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

1. Whether the complainant proves that the opposite party unlawfully withheld reimbursement of Rs.84688/- to him which act of opposite party is amounts to deficiency in service and unfair trade practice?
2.  What order?

8.       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 ::

9.        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/141116/012018/004368  dated 11.09.2017 from the opposite party by paying  premium of Rs.6,706/- for Rs.10,00,000/- valid from 11.09.2017 to 10.09.2018 and the basic sum  of Rs.3,00,000/- being covered by the mediclaim policy  obtained from Reliance Insurance Company bearing policy No.1403272825000309 dated 27.03.2017 and he further submits that the complainant admitted to Prashanth Superspeciality Hospital, Chennai  for knee replacement surgery and incurred hospitalization medical expenditure of Rs.4,43,660/- and also he incurred Rs.6,400/- towards pre-hospitalization medical expenditure and Rs.3,227/- towards post hospitalization medical expenditure totally Rs.4,53,827/-.  Out of which the Reliance General Insurance company reimbursed Rs.3,00,000/- only to Prashanth Superspeciality Hospital and the complainant has paid balance amount of Rs.1,43,660/-.  The opposite party is liable to reimburse balance medical expenditure of Rs.1,53,287/-,  but out of which the opposite party reimbursed only Rs.68,599/- and  due a sum of Rs.84,688/- to complainant.  Therefore the complainant sought the relief of reimbursement of Rs.84,699/- from the opposite party.

10.  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 the Reliance General Insurance Company as per the terms and conditions of the policy issued by it to the complainant was settled Rs.3,00,000/- and the opposite party has also settled Rs.68,599/- vide cheque No.613041 dated 07.04.2018 and also settled amount of Rs.6,150/- vide cheque No.655100 dated 06.09.2018 to the complainant 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 complainant counsel submitted that there is no merits in the complaint,  hence, the same is liable to be dismissed. 

11. We have perused the copies of documents produced by the complainant such as legal notice, health insurance policy bearing No. No.P/141116/01/2018/004369  and the copy of letter issued by Reliance General Insurance Company- towards payment of Rs.3,00,000/- to complainant.  Claim Form and the bill Assessment Sheet of Star health and Allied Insurance Company Limited and other medical reports, Discharge summary issued by Prashanth Superspeciality Hospital, Chennai, inpatient credit bill of Prashanth  Research Centre, Chennai etc.,.

12.   The opposite party has also produced documents such as proposal form of complainant and Star Super Surplus (Floater) Insurance Policy issued to complainant, discharge summary and bill assessment sheet and pre-payment and customer information sheet star super surplus (Floater) Insurance policy mentioning the terms and conditions of policy issued to complainant.

13.  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 Reliance General Insurance Company of Rs.3,00,000/- to the complainant and payment  of Rs.74,749/- made by opposite party to the complainant towards claim of the complainant in respect of medical reimbursement it appears that the Reliance General Insurance Company and the opposite party have properly reimbursed admissible amount of Rs.3,00,000/- + Rs.74,749/- respectively totally Rs.3,74,749/- towards medical claim of complainant out of Rs.4,53,827/-  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.

14. 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)