D.O.F:15/03/2023

                                                                                                         D.O.O:29/09/2023

IN THE CONSUMER DISPUTES  REDRESSAL COMMISSION, KASARAGOD

CC.78/2023

Dated this, the 29^th  day of September 2023

PRESENT:

SRI.KRISHNAN.K                          : PRESIDENT

SMT.BEENA.K.G                          : MEMBER

Mohammad Sukkani Mohidin, Aged 66 years,

S/o Mohidin Kunhi,

R/at Sukkani Villa, Near Railway Gate

Uppala, Post Uppala,

Kasaragod District – 671322                                                : Complainant

(Adv: Shamnaz Ameer)

And

The united India Insurance Company Ltd,

Divisional Office – 010500,

Catholic Centre – 64,

Armonian street,

Chennai – 600001                                                     : Opposite party

ORDER

SMT.BEENA.K.G  : MEMBER

          The case of the complainant is that he joined the Arogya Raksha (group health insurance scheme) with policy No: 105002022484100000170717 on 01/02/2022 and the said policy is valid up to 31/01/2023.  The policy coverage of the said policy is Rs. 7,00,000/- in case of admission in hospital.  This policy had full coverage room rent, Icu, surgeon, hospital expenses etc.  There after the  complainant had ankle fracture and was advised to go for an ankle implant.  When admitting in hospital the complainant took permission from Opposite party.  Thereafter on 24/11/2022 again he admitted for removal of the implant ,that was also duly informed to opposite party.  But when the complainant submitted the discharge bill and claim form, the opposite party told that they could not pay the total bill amount of Rs. 10,13,48/- and they partly paid only Rs. 58,000/- and the complainant was constrained to arrange the balance amount of Rs. 43,348/- at the time of discharge.  Thereafter the complainant contacted the opposite party several times but the opposite party postponing the payment by saying flimsy excuses.  A rranging of the balance bill amount of Rs. 43,348/- was a  painful experience to him at the time of discharge.  The denial of the bill amount by the opposite party caused severe mental agony and loss to the complainant.  The allegation of the complainant is that there is gross negligence and deficiency of service on the part of opposite party.  The complainant was caused to send a lawyers notice to opposite party on 27/01/2023 and the same was served on 01/02/2023.  But the opposite party did not send any reply neither refund the balance amount to the complainant.  Therefore the complainant prayed for refund of the balance amount of Rs. 43348/- with a compensation of Rs. 10,000/- along with a cost of Rs. 2000/- from opposite party.

          Notice of opposite party served, but he remained absent .name of opposite party called absent set exparte.

          The complainant filed proof affidavit in lieu of chief examination and the documents produced are marked as Ext A1 to A5. Ext A1 is the policy, Ext A2 is the discharge summary, Ext A3 is the discharge bill, Ext A4 is the lawyer notice and Ext A5 is the acknowledgment card.

The question raised for consideration are:

1. Whether there is any negligence or deficiency in service on the part of opposite party in partly allowing the discharge bill?
2. Whether the complainant is entitled for relief?
3. If so what is the relief?

For convenience issues No: 1 to 3 he can be discussed together.

          Here the complainant joined in Arogya Raksha group health insurance scheme and the said policy is valid up to 31/01/2023.  The specific policy had full coverage on room rent Icu, surgeon hospital expenses etc.  Thereafter the complainant had an ankle fracture and he was admitted for ankle implant.  Expecting the policy amount the complainant had undergone ankle implant.  on 24/11/2022 he again admitted in hospital for removal of the implant.  All this admissions and treatments are duly informed to the insurance company.  But the grievance of the  complainant is that when  he submitted the discharge bill and claim form the company paid only Rs. 58,500 /-of the bill amount and he was constrained to arrange the balance amount of Rs. 43348/-  from his friends and relatives caused severe mental agony to the complainant at the time of discharge.  The complainant produced the policy certificate which is marked as Ext A1 , Ext A2 is discharge summary, Ext A3 is discharge bill, Ext A4 lawyer notice and Ext A5 is the postal acknowledgment.  While perusing the affidavit and documents produced by the complainant it is clear that this is a fit case to get the insurance amount.  Ext A1 to A5 proves that the complainants case is genuine due to the partial allowing of the bill the complainant had undergone untold miseries.    The complainant was compelled to arrange the balance amount of Rs. 43,348/- after discharge.   He took hand loan from his friends and relatives.   After consultation with the opposite party the complainant was admitted in hospital on assurance that the insurance company will bear the full expense of treatment.  After discharge only he came to know that only Rs. 58,500/- was paid by the company and he has to arrange the balance amount.

          The complainant was caused to send a lawyer notice demanding the balance bill amount.  But the opposite party neither replied nor paid the amount.  There is grievous deficiency in service and negligence on the part of opposite party which caused severe mental agony and financial loss to the complainant.  The complainant’s loss and agony has to be compensated.  The complainant is entitled for the balance bill amount with compensation and cost.  And the opposite party is liable to pay the same.  The prayer of the complainant is for the refund of the balance amount with Rs. 10,000/- as compensation and Rs. 2000/- as cost.  The complainant’ is entitled for the relief sought in the complaint.  The complaint is filed through a counsel, in such a situation we usually allow Rs. 5000/- as cost of litigation.

          In the result complaint is allowed directing opposite party to pay the balance amount of Rs. 43,348/- along with a compensation of Rs. 10,000/- (Rupees Ten thousand only) and Rs. 5000/- (Rupees Five thousand only) to the complainant within 30 days from the date of receipt of this order.

     Sd/-                                                                                              Sd/-

MEMBER                                                                                      PRESIDENT

A1- Policy –cum-certificate for Arogya Raksha

A2- Discharge summary

A3- discharge bill

A4- lawyer notice

A5- Acknowledgment card

     Sd/-                                                                                     Sd/-

MEMBER                                                                            PRESIDENT

Forwarded by Order

                                                                      Assistant Registrar

Ps/