Karnataka

Kolar

CC/124/2023

Mr.Altaf Ali Khan - Complainant(s)

Versus

The New India Assurance Co Ltd - Opp.Party(s)

21 Nov 2023

ORDER

Date of Filing: 29/08/2023

Date of Order: 21/11/2023

BEFORE THE KOLAR DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, OLD D.C. OFFICE PREMISES, KOLAR – 563 101.

 

Dated:21^stDAY OF NOVEMBER 2023

SRI. SYED ANSER KALEEM, B.Sc., B.Ed., LL.B., …… PRESIDENT

SMT. SAVITHA AIRANI, B.A.L., LL.M., …..LADY MEMBER

CONSUMER COMPLAINT NO:124/2023

 

Mr. Althaf Ali Khan,

Aged about 42 years,

Permanently resident of

Phoolsha Mohalla,

Kolar District.      

(Rep. by In-Person)                                     ……. Complainant.

                                                 - V/s –

 

The New India Assurance Co.Ltd

Bangalore Regional Office,2-B,

Unity Buildings Annexe,

P. Kalinga Road (Mission Road),

Bangalore-560027.                                                                                     

(Rep. by Sri. B. Kumar, Advocate)                          ..….Opposite Party.

 

 

-: ORDER:-

BY SRI. SYED ANSER KALEEM, PRESIDENT.,

1. That the complainant has filed this complaint Under Section 35 of the Consumer Protection Act 2019 against the OP Insurance Company alleging deficiency in service and prays to direct the Op to reimbursement full amount against the medical expenditure incurred in terms of the insurance Policy and seeking direction to the Op insurance company to pay the remaining claimed balance of amount of               Rs. 1,05,942/- and also direct the OP to pay the compensation of Rs.4,000/- towards the Xerox copies and travelling expenses.
2. The brief facts:- That the  complainant  is the employee of the Karnataka State Pollution Control Board, from the KSPCB office and he was taken the health insurance policy from the New India Assurance Company Ltd” and the premium was paid by the employer of the complainant.  That the employer was paid a sum of Rs. 91,88,777/- for all the employees as a corporate policy.  Further it is stated that, the policy bearing No. is 67030234220400000007 and the sum assured is Rs.3,00,000/- that the validity  period of policy is from 26/09/2022 to 25/09/2023.

 

3.  Further stated that, the complainant was got admitted to the New Kamadhenu Nursing Home and was treated in the hospital from 06/01/2023 to 08/01/2023. The complainant paid the Hospital bill a total sum of Rs.1,38,658/- and after that he submitted the claim bill to the OP Insurance Company for reimbursement of the medical expenditure incurred, but the OP Insurance Company had approved only Rs.32,716/- and further complainant stated that, the remaining amount of Rs.1,05,942/- was not paid.

 

4. Further stated that, the complainant made a complaint to the grievance cell by phone call and also approached the office of the Ombudsman and registered complaint. The complaint No: BNG-MISC-H-049-22230777, in the hearing of the Ombudsman office ordered to pay for only three day’s insulin amount.

 

5. The complainant further stated that, in the year 2021 he claimed the insurance amount in the IFFCO TOKIO GENERAL INSURANCE that insurance company first deducted insulin amount, but after giving complaint to ombudsman settled the full claimed amount.

 

6. Further complainant stated that, op insurance company by not honored the full legitimate claim, hence alleged that the Op insurance company committed deficiency in service. Hence this complaint.

 

7. On issuance of notice OP appeared through their counsel and filed the version.  In the version Op admitted that the health policy issued by them to the complainant with assured sum of Rs. 3,00,000/- for the period from 26/09/2022 to 25/09/2023 and the issuance of the policy is subject to terms and conditions of the policy.  That the Op denies all the allegation made in the complainant and admission to the hospital and incurred expenditure of Rs.1,38,658/- and denied the fact of causing deficiency in service.

 

8. It is contended that, they settled the claim for an amount of Rs.32,716/- only.  Further it is contended that, the room rent, boarding and nursing expenses as provided by the hospital not exceeding 1.0% of the sum assured(without cumulative bonus).  Further contended that, the complaint is false and frivolous one.  On the above said grounds Op insurance company pray to dismiss the complaint.

 

9.  In order to prove the case of the complainant, complainant has filed his affidavit evidence along with the copies of the documents.  Further the Op insurance company also filed the affidavit evidence with documents.

 

10.  On the basis of the pleadings of the parties  and the evidence placed on record, the following points will do arise for our consideration:-

             (1) Whether complainant has proved deficiency in service on the part of the Op as alleged in the complaint?

             (2) Whether the complainant is entitled for the relief as sought in the complaint?

             (3)  What Order?

Our findings on the above points are:-

POINT No.(1) & (2):-     In the Negative.

POINT No.(3):-            As per the final order

                                    for the following.

 

                                    REASONS

11. POINT No. (1) & (2):  These two points are interlinked to each other and in order to avoid repetition of discussion of facts and for brevity, these points will taken up together for common discussion.

 

12. On perusal of the pleadings and the evidence placed on record, it is undisputed fact that, the complainant is working in the Karnataka State Pollution control Board and his employer taken the group health insurance policy bearing No.67030234220400000007 and the validity period of the policy commencing from 26/09/2022 to 25/09/2023.  It is grievance of the complainant is that, he was admitted to the New Kamadhenu Nursing home for treatment of viral fever as evidenced by the order of the insurance Ombudsman and the complainant incurred medical expenditure to an extent of Rs.1,38,658/- whereas the Op insurance company settled claim amount to extent of        Rs. 32,716/-only against the Rs.1,38,658/-.  Hence complainant alleging deficiency in service filed this complaint.

Per contra that the Op contended that they settled the claim of the complainant in accordance with the terms and conditions of the policy.

13. Whereas the complainant to substantiate his case, relied on the previous settlement claim during the year 2021 and hence canvassing that same yardstick will be adopted.

On perusal of the copy of the discharge summary it reveals that complainant was treated for viral fever from 06-01-2023 to 08-01-2023 and the same cannot be disproved by the Op and hence the copy of the discharge summary is accepted. Further on perusal of the following bills incurred towards medical expenditure as follows.

 

	06-01-2023	Lakshmi Medicals	Rs. 59,628/-
		Vinay Diagnosis lab	Rs.   1,300/-
		Ragavendara medicals	Rs. 12,778/-
		Ragavendara medicals	Rs.   1,173/-
		Ragavendara medicals	Rs.   1,492/-
		Ragavendara medicals	Rs.   1,173/-
		Ragavendara medicals	Rs.   1,138/-
		Lakshmi Medicals	Rs. 23,820
		Vinay Diagnosis lab	Rs.     400/-
	08-01-2023	Ragavendara medicals	Rs.   1,173/-
	08-01-2023	Ragavendara medicals	Rs.   1,166/-
	08-01-2023	Ragavendara medicals	Rs.   7,940/-
	08-01-2023	New Kamadhenu Nursing home final bill of the hospital	Rs. 37,713/-

                                                              Total Rs. 1,50,894/-

14. On perusal of the order of the insurance ombudsman dated 03-07-2023, it discloses that as per the submission and acceptance of the complainant that he was taken the insulin for lifelong purpose and purchased the same and the same is treated as outside purview of the policy.  However, that the Op contended that, Novarapid penfil and Lantus penfil which are purchased high quantity for future days. Hence same is not covered under the policy. On perusal of the bill generated the medical stores during the day of treatment in the hospital i.e Lakshmi medical stores reveals that complainant was taken Novarapid penfil to extent of Rs.59,628/- and same cannot be taken into consideration as same is admitted before the insurance ombudsman.  Also on 07-01-2023 Lantus penfil bill issued by the Lakshmi medical stores it discloses that, complainant was purchased the said medicine for an extent of Rs.23,820/- and facts admitted by the complainant before the insurance ombudsman.  Hence the insurance ombudsman rightly held that the said purchase of medicines to extent of Rs.59,628/- and Rs.23,820/- and in total it comes to Rs.83,448/- Hence after deducting Rs,83,448/- from the total amount of         Rs. 1,50,894/-it comes to Rs.67,440/-. Whereas the complainant in order to prove that the other drugs purchased by him as per the prescription of the Doctor concerned to Nursing home during the period of his admission to nursing home. Hence in absence of cogent evidence, the bills produced by the complainant cannot acceptable one. Furthermore that the Op insurance company produced the report of the claim settlement of the patient it discloses that, what are bills which are not comes under the purview of the claim, in our view in absence of cogent evidence and also who has given the prescription  there is no evidence on record. That the insurance company rightly considered the bills properly and settled the claim for Rs.32,716/- in favour of the complainant. On overall perusing the evidence placed on record as well as the orders passed by the insurance ombudsman reveals that there is no deficiency in service and the complainant failed to prove the deficiency in service on the part of the Op. Hence complainant is not entitled for the relief as sought in the complaint.  Accordingly we answer the point No.(1) and point No.(2) are in the negative.

 

15.  POINT NO. (3):-   On the basis of answering the Point No. (1) & (2) and the reasons assigned thereon, we proceed to pass the following.

                                       ORDER

1. The complaint is hereby dismissed. No order as to cost.
2. Send a copy of this order to both the parties at free of cost.

   (Dictated to the Stenographer, transcribed by him, corrected and then pronounced by us on this 21^st DAY OF NOVEMBER 2023)

 

 

 

 

                MEMBER                           PRESIDENT