JUDGMENT

Shri A.K.Patra,President:

1. The captioned consumer complaint is filed by the complainant named above inter alia alleging deficiency in service &unfair trade practice on the part of the Ops for denial of cashless treatment in the named hospital and for delayed in settlement of claim & for release of less than claimed amount under health insurance policy.
2. The complainant seeks for the following reliefs:- (i) A direction to the Ops to pay Rs, 3,44,640 along with interest till payment of said amount which  include litigation cost and compensation for mental agony &  sufferings and (ii) further pray for a direction to the Ops not to repeat such negligence causing harassment to any other insured person and (iii) pray for all other relief as the Honorable Forum/Commission may deems fit & proper for the best interest of justice.
3. The factual matrix leading to the case of the complainant as emerged from the case record is that ,the complainant was  insured with the insurer “Star Health and Allied Insurance Company Limited “i.e under   “Senior Citizens red Carpet Health Insurance Policy”  paying yearly premium of Rs.58,587/- vide Policy No. P/161130/01/2023/080382 for sum assured Rs.15,00,000/-. The period of policy was 20^th September 2022 to 19^th September 2023 which   assured cashless treatment facility to the insured complainant. It is contended that, during the period of policy the complainant suddenly fell ill at Bangalore and was admitted in “Kauvery Hospital”, electronic City, Banglore and that, due to critical health condition he was admitted in the ICU but the said hospital refused to provide cashless treatment for which the complainant suffered harassment & mental agony also suffered mentally disturbed for arrangement of money. Accordingly , the complainant is  entitle to get compensation of Rs.3,00,000 along with the medical expenses incurred i.e. of Rs.1,35,638/-.It is further contended that, the  OP 2 after receipt of the claim application through OP 1 have released only Rs.90,998/-  which frustrate the objective of the insurance policies. It is further contended that,  “Kaveri Hospital,” where the complainant  under gone treatment,  was  listed by the insurance company for availing  cashless treatment  under the said  insurance policy  but the “Kaveri Hospital,”hospital denied to provide cashless treatment for which the complainant  suffered financial hardship , mental agony & harassment . Hence, this complaint seeking above mentioned relief(s).
4.  To substantiate his claim the complainant has filed the following documents (i) Insurance Policy vide No. P/161130/01/2023/080382 (ii) Admission discharge certificate (iii) Money receipt and its break up (v) Photographs (iv) KYC documents (v) Repudiation of claim dt.18 Jan 2023. (vi) Claim medical rejection documents dt.19.01.2023 (vii) Reclaim medical rejection dt.21.01.2023 (vii) Reminder letter dt,.28.01.2023 to submit the payment documents (a) Pan Card (vii) letter dt.23.03.2023  to submit the NEFT details. (viii) e-mail details dt. 30^th  March 2023 received from Insurance ECB <insurance.ecb@kauveryhospital.com.
5. Notice to OP 1 through Registered Post is properly served on dt.  15.02.2023 vide RP Consignment Number RO096572356IN and to the OP 2 on dt. 13.02.2023 vide Consignment Number RO096572373IN .Both the OP 1 & 2 have appeared through their authorized person Mr. Purnendu Ku. Rath ,S/O- Rajkishore Ratha ,Ashok Nagar,Plot no. 23 (E) Bhubaneswar along with their learned Mr. Chinmoy Patra but failed to submit their written version within the stipulated time period though sufficient opportunities have  been availed .The written version filed by the OP 1 & 2 in a belated stage is not accepted in view of the order of Hon’ble Supreme Court of India passed in New India Assurance Co. Ltd. Vrs. Hilli Multi Purpose Cold Storage Ltd. However, availed opportunities to participate in the hearing of the case without Written Version.
6. During hearing of this case the Ld. Counsel for the Op 1 & 2 submits that, this complaint before this commission is not maintainable as all the allegations raised is baseless and without  having any supporting documents to prove his case and that, this Commission has no jurisdiction to adjudicate this complaint. It is further submitted that, the claim has been reported in the 2^nd year of the insurance policy. The complainant was admitted at “Kauvery Hospital”, Bengaluru on dt.20.11.2022 and was discharged on 25.11.2022 for treatment and the insured did not raise any preauthorization request to avail “cashless facility” and submitted claim documents for reimbursement of claim. Accordingly out of total claim amount of Rs .1,80,620/- , the Ops  have already paid Rs.90,998/-  which are admissible under the Policy terms and the rest deductions are towards non-payable items i.e. as per terms & conditions of the policy 30% co-payment  to be borne by the insured.
7. The Learned Counsel for the Op 1 & 2 placed reliance on the judgment of the Hon’ble Supreme Court in Satwant Kaur  Sandhu  vrs  New India Assurance company Ltd.(2009), Sudesh Gupta Vrs. ICICI Prudential LIC Ltd. CPR-2011(3) P.g.149 National Commission, In LIC of India & others Vars. N.P.Nagarathana-CPR-2012(2),National Commission, LIC & Another Vrs. Smt.S.Sandhu (CPR) 2006(5) p.g.258 The Hon’ble Supreme Court, National Insurance Co. Ltd. Vars. Aparna Kathar-CPR-2014(3)p.g.697, and submitted that, claim under medi claim policy can only be allowed within terms and conditions of the concerned policy.
8. To substantiate their claim the OP 1 & 2 has filed the letter of repudiation dt.18 Jan 2023 with the pretext of true copy of the claim assessment order. But no copy of claim assessment order is filed by the OP 1 & 2 for our perusal.
9. The Opp.Party No.3 by written version contended that, OP 3 is merely a facilitator of services on behalf of third party service providers and it provides a platform where the service providers and the customers meet each other. It simply markets the insurances services provided by the Insurance Company & conditions pertaining to the insurance policy and help the user make an informed choice while purchasing the policy. The OP 3 does not incur any liability on the conduct of a third party/service provider. It is further contended that, Section 79 & 81 read with Section 2(w) of the Information Technology Act 2000 clearly exempts the liability of an intermediary. It is further submitted that, the complainant has purchased a health insurance policy through the website of the OP 3 and the policy was issued by the OP 1 & 2 and hence, the OP 1 & 2 is liable for accepting or rejecting of the claim.
10. The Op 3 further submitted that, the complainant claimed Rs.1,80,000/- out of which Rs.90,998/- was approved to the complainant after some deductions as per the policy terms and also due to lack of documentation. The details of claim settlement are communicated to the complainant via claim settlement letter. The sole discretion within the purview of the decision making in regards to any policy or policy holder lies with the insurer. It is further contended that, the complainant never paid any consideration to the OP 3 as such the relations of the “consumer” and the “service provider”  does not exist between the complainant and the OP 3 for which  the present complaint is liable to be dismissed against the OP 3. There is no cause of action against the OP 3. The OP 3 is not liable for any loss caused to the complainant.
11. The complainant led his evidence on affidavit and proved his contention. The facts stated in his evidence affidavit are corroborating with the averments of the complainant petition remain un-rebutted.
12. The OP 3 also filed his evidence on affidavit ,averment of which are corroborating with the averment of their written version .The  Op 1 & 2 lead no evidence affidavit as prescribed under C. P. Act 2019.
13. Heard. Peruse the material on record. We have our thoughtful consideration to the submission of rival parties and gone through the judgments cited by the learned counsel for the parties present.
14. After perusal of the complaint petition, written version and all the documents relied on by both the parties placed in the record, the points for consideration before this Commission are :- (i) Whether the complainant is the consumer of the Ops ? (ii) Whether there is any deficient service & unfair trade practice on the part of Ops caused injuries to the complainant?   (iii) And whether the complainants are entitling for the relief(s) claimed?
15. Here in this case it remain un disputed that ,the complainant was insured with the insurer “Star Health and Allied Insurance Company Limited” i.e under  a “Senior Citizens red Carpet Health Insurance Policy”  paying the yearly premium of Rs.58,587/- vide Policy No. P/161130/01/2023/080382 for sum assured Rs.15,00,000/-. The period of policy was 20^th September 2022 to 19^th September 2023 which assured cashless treatment facility to the insured complainant and that, during the period of policy the complainant suddenly fell ill at Bangalore and was admitted in “Kauvery Hospital”, electronic City, Banglore and that, due to critical health condition he was admitted in the ICU but the said hospital refused to provide cashless treatment. Later on the claim of the complainant is settled at Rs 90,998 against his  claim amount of 1,80,620/-by deducting 30% Co-pay and disallowed the rest claim amount for the reason that, those are not admissible under the terms & conditions of the policy.
16. The complainant placed reliance on the e-mail details dt. 30^th March 2023 received from Insurance ECB <insurance.ecb@kauveryhospital.com. which is their placed on the record clearly contended that, “Due to Tariff related issues, Star health Insurance Cashless facility was temporarily withhold by Star Health between Date 21 Oct 2022 to Nov 2023” remain undisputed as such it is clearly proved that, during treatment of the complainant i.e as on dt.20.11.2022 (date of admission) to   25.11.2022 (date of discharge) at “Kauvery Hospital”, Bengaluru the cash less medical treatment facilities for the person insured  with “Star Health and Allied Insurance Company Limited” i.e under  a “Senior Citizens red Carpet Health Insurance Policy”    was withdrawn by the insurer/OP 1&2 and accordingly cash less medical treatment facilities is not provided to the complainant .
17. The Op 1 & 2 has not specifically denied the fact that, the “Kauvery Hospital”, Bengaluru was named in the said Senior Citizens red Carpet Health Insurance Policy purchased by the complainant for cashless treatment of the insured. Nothing placed on record to hold that , the matter of fact that “Due to Tariff related issues, Star health Insurance Cashless facility was temporarily withhold by Star Health between Date 21 Oct 2022 to Nov 2023”was ever been notified  or have ever intimated to the insured/complainant in any form before his admission at the “Kauvery Hospital”, Bengaluru rather it is proved on affidavit by the  complainant  that, he suffered harassment & mental agony also suffered mentally disturbed  for arrangement of money when the “Kauvery Hospital”, Bengaluru denied cash less treatment to the complainant dishonoring  the insurance policy issued from the Star Health & Allied Insurance Co. Ltd. Entitled to be compensated by the insurance company /OP1&2 
18. During hearing of this case the complainant submitted that, all required documents have been sent to the insurer for settlement of the claim but the insurance company has time & again asked to submit same document only to harass the complainant and tried to avoid their liability under the policy.  It is further submitted that, the insurance certificate issued to the complainant contented no terms to deduct any amount spent for medical treatment of the insured/complainant as such deduction from the total medical expenditure is arbitrary one.  We found much weight on the submission of the complainant as it has been proved by on affidavit of the complainant.
19. Admittedly the contract of insurance claim is based on utmost bonafied intention of the parties. Both the parties are expected to disclose each other relevant fact at the time of commencement of policy including the term & condition but not at the peril.
20. The Ops have not placed on record any documents whatsoever to establish that, there is certain term &  condition of the policy for  admissibility & deduction of  any amount accrued by the insured during treatment as such we are of the opinion that , the deduction made against the claim of the complainant is not proper .it is seen from the documents available on the record and detail conversion of  the authorized person of both insured & insurer that, all the documents necessary for the settlement of the claim has already been submitted to the insurer/ops but  it  was asked time & again to submit same papers which proved the  ill intention of the insurer to avoid their liability under the policy  also such acts  clearly proved unfair trade practice &  deficient service on the part of OP 1 &2 . If the O.Ps were not satisfied with those documents it was open for them to investigate the truth independently for settlement of the claim earliest but we found nothing placed on record that, O.Ps could have took pain  to move forward for early settlement of the claim  is nothing but deficient service & unfair trade practice on the part of OP 1 & 2 certainly  caused financial loss & mental agony to the complainant who is an old age senior citizen  cannot be compensated in any manner however, award of  minimum monetary compensation of Rs 2,00,000/-(two lakhs) against claim of 3,00,000/  may heal the injuries of the complainant to some extent .
21. Putting the insured in harassment by not providing cash less treatment in the named hospital and asking for submission of documents time & again as per the sweet will of the insurer is nothing but unfair contract as defined u/s 2(46)(vi) of C.P.Act,2019 which may be quoted here :-  “imposing on the consumer any unreasonable charge, obligation or condition which puts such consumer to disadvantage” is certainly went against the interest of the consumer is  not  permissible under C.P.Act . Here the O.Ps have falsely represents that, they will provide cash less medical treatment as insurance benefit under “Senior Citizens red Carpet Health Insurance Policy”  during hospitalization of the complainant but Op 1 & 2 have admittedly failed to provide cash less treatment during critical situation of the old aged senior citizen/here the complainant & tried   to escape from their  liability is certainly an act of Unfair Trade Practice as such the interest of the consumer is to be protected in the sprite of C.P Act 2019 and the OP/insurance company should be discourage from repetition of same acts of unfair trade practice with any other bonafide insured person as such we think it proper to impose exemplary cost of not less than Rs.5,00,000/(five lakh)  payable to the Consumer Welfare Fund of the State of Odisha so that, the OP/Insurance company shall not repeat the   same act of unfair trade practice .
22. The complainant has pleaded that, he has incurred  expenditure Rs 1,93,769/ for his treatment and by deducting 30% thereof towards Co-pay, the complainant is entitled to get Rs 1,35,638 from the insurer/Op 1&2 as insurance benefit but no supported documents in this regard  is filed by the complainant . Rather, on perusal of the medical bills placed on the record it is found that, the complainant has paid Rs.180620/-for his treatment and claimed  the same amount i.e Rs.1,80,620/- towards the expense incurred for his treatment  under gone while insurance policy was in force   but the insurance company has settled the claim at Rs 90,998 /only which reveled from the bill assessment sheet –member payment approved on dt.24.01.2023 .It  is found form the insurance paper that, the O.Ps have assured to pay maximum 15.00.000/-(fifteen lakh)  under the subject insurance policy .It is further found that, required documents for settlement of the claim has already been submitted to the insurer and copies thereof are available in the case record as such we are of the opinion that ,the Insurance company is  liable to release deducted amount of Rs. 49,893/- with interest @ 9% P.A from the date of discharge i.e.  from 25.11.2022 to it realization to the complainant  as we have already hold that , the deduction made against the claim of the complainant is not proper.
23. In view of the discussion stated above we are of the opinion that, the complainant is the consumer of the Ops by purchasing insurance policy of the OP 1 & 2 through the Op 3 .The  OP 1 & 2 denied  cash less treatment to the complainant at the peril during insurance period and delayed in settlement of claim of insured by asking production of same documents time & again and that ,there is arbitral deduction from  actual expenses of treatment certainly  deficient service and unfair trade practice on the part of the OP 1 & 2/Insurer which caused financial hardship & mental agony to the complainant   cannot be denied  as such there is sufficient cause of action against the Ops to present this complaint. This complaint is presented on 07.02.2023  before this Commission within the jurisdiction of which  the complainant is reside as such the complaint is found to be in time, well maintainable under C.P.Act,2019 before this commission for adjudication.  In absence of cogent evidence the preliminary objection raised by the Ops that, complaint is not maintainable before this commission under C.P Act is here by rejected. We found nothing deficient service or unfair trade practice on the part of the OP 3 as such complaint is liable to be rejected against the Op 3 only.
24. Based on the above discussion this complaint is allowed in part against the OP  1 & 2 and dismissed against the Op 3 with the following directions:-                                               

                                                         ORDER

1. The Star Health & Allied Insurance Co. Ltd./ Op 1 & 2 is here by  directed to release the sum of  Rs. 49,893/- with interest @ 9% P.A from the date of discharge i.e.  from 25.11.2022 to its realization to the complainant  as insurance benefit under the subject insurance policy and,
2. Further directed to pay Rs.2,00,000/-(two  lakh ) as compensation  to  the complainant towards financial hardship & mental agony suffered by the complainant which include litigation expenses of this complaint .
3. The Op 1&2 / Star Health & Allied Insurance Co. Ltd is  further directed to pay  Rs 5,00,000/- (five lakh) as exemplary cost to the Consumer Welfare Fund of the State of Odisha.
4. It is further directed to comply the order within 45 days of receiving of the copy of this order, failing which Op 1 & 2 / Star Health & Allied Insurance Co. Ltd shall pay Rs 500/-per day  as delayed compensation to the complainant till its realization.
5. The consumer complaint is partly allowed in above term. Pending application if any is also stands disposed of accordingly.

Dictated and corrected by me.

                 Sd/-

             President

                                         I   agree.

    Sd/-                                                                

Member

         Pronounced in open Commission today on this 25^th day of October 2023, under the seal and signature of this Commission. The pending application if any is also disposed off accordingly.

         This complaint could not be decided within the prescribed period of time in want of quorum of this Commission

         Free copy of this order be supplied to the parties for their perusal or party may download the same from the Confonet be treated as copy served to the parties. Complaint is disposed of accordingly.