DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM
Dated this the 23rd day of June, 2023
Filed on: 17/03/2016
PRESENT
Shri.D.B.Binu President
Shri.V.Ramachandran Member
Smt.Sreevidhia.T.N Member
CC NO. 172/2016
Between
COMPLAINANT
JUSTIN THOMAS P. A, S/O. P.T. AUGUSTINE, SWAPNA, 32/1637, ABRAHAM MASTER ROAD, PALARIVATTOM P.O., KOCHI-682 025
(Rep. by Adv. K. S. Dilip, 32/2291, B- 5, 3rd Floor, Vasudev Complex, Palarivattom, Kochi-682025.)
VS
OPPOSITE PARTY
STAR HEALTH AND ALLIED INSURANCE CO. LTD. ZONAL OFFICE, 4TH FLOOR, CARMEL TOWERS, COTTON HILL P.O., VAZHUTHACAUD THIRUVANANTHAPURAM-695 014. Rep by its Manager
(Rep. by Adv. R.S. Kalkura)
FINAL O R D E R
DB.Binu, President
- A brief statement of facts of this complaint is as stated below:
The complaint was filed under section 12 (1) of the Consumer Protection Act,1986. The brief facts, as averred in the complaint, are that the complainant is a senior citizen and policyholder of the opposite party, holding a Medi-claim policy known as the Senior Citizens Red Carpet Insurance Policy. The policy is valid until February 26, 2016. The complainant incurred medical expenses of Rs.2,34,257 for the implantation of a pacemaker and submitted a claim to the insurance company. After persistent follow-up, the company considered the claim but made improper deductions, resulting in an amount of Rs.80,441 being allowed instead of the promised amount of Rs.1,12,531.
The complainant had filed a complaint before the Insurance Ombudsman. The Ombudsman is of the view that nothing can be done by it when there is denial by the insurance company and the statement made by the insurance company is correct and acceptable, which is without appreciating any of the contents in the right perspective and also without considering the propriety of the deductions made by the company. It is also without hearing the complainant confirming the decision of the opposite party. The award of the Ombudsman is not accepted by the complainant.
The complainant seeks an order to allow the balance claim amount of Rs.32,090 and compensation of Rs.25,000 for mental agony, along with Rs.10,000 as the cost of the proceedings.
2). Notice
The Commission issued a notice to the opposite party, which was duly received by them. In response, the opposite party submitted their version.
3). THE VERSION OF THE OPPOSITE PARTY.
The opposite party presents its argument against a complaint filed by the complainant regarding a health insurance policy. The complaint does not meet the criteria set by the Consumer Protection Act, of 1986, and it is flawed due to the non-joinder of necessary parties. They explain that the policy has specific exclusions and sub-limits for claims, including a co-payment requirement for pre-existing diseases. The complainant submitted a claim for medical treatment, but the opposite party found that the complainant had a pre-existing condition and applied the applicable sub-limits and co-payment. The claim was settled accordingly, and the complainant later filed a complaint with the Insurance Ombudsman, which was dismissed. The opposite party argues that the complainant's actions, including accepting the settlement and encashing the check, nullify their status as a consumer and render the complaint is baseless. They accuse the complainant of filing the complaint with malicious intention to harass and gain illegal benefits. The opposite party denies any deficiency in service or unfair trade practices and asserts that they are not liable for further payment or compensation. They request the dismissal of the complaint with costs.
4) . Evidence
The complainant had produced a proof affidavit and 8 documents that were marked as Exhibits-A-1 to A-8. The complainant was examined as PW-1.
Exhibit A-1. Copy of policy document - Policy No. P/181200/01/2015/009982 dated 4/3/2015.
Exhibit A-2. Discharge Summary dated 27/3/2015 issued from Amrita Institute of Medical Sciences and Research Centre.
Exhibit A-3. Bill No. IPF/IPB BC01/14/23736 dated 27/3/2015 with Annexures I and II.
Exhibit A-4. Bill Assessment Sheet dated 3/8/2015 issued by Star Health and Allied Insurance Co. Ltd.
Exhibit A-5. Bill Assessment Sheet dated 9/10/2015 issued by Star Health and Allied Insurance Co. Ltd.
Exhibit A-6. Award of the Insurance Ombudsman dated 5/2/2016.
Exhibit A-7. Notice of demand dated 26/10/2015.
Exhibit A-8. Postal receipt for sending the Notice of demand dated 26/10/2015.
The opposite party had produced a proof affidavit and 10documents that were marked as Exhibits-B-1 to B-10. The opposite party was examined as DW-1.
Exhibit B-1. A true copy of the Policy schedule
Exhibit B-2 Original Policy Condition.
Exhibit B-3. A true copy of the Proposal form.
Exhibit B-4. Original Claim Form.
Exhibit B-5. Original Discharge Summary.
Exhibit B-6. Original Final Bill.
Exhibit B-7. Original Certificate regarding payment of Cheque No: 403883 dated 21.08.2015 of Indian bank, Thycaud branch
Exhibit B-8 Original Award copy of Hon'ble Insurance Ombudsman dated 28.01.2016
Exhibit B-9. Authorization letter.
Exhibit B-10. Clarification on Bill Assessment Sheet.
5) The main points to be analysed in this case are as follows:
i) Whether the complaint is maintainable or not?
ii) Whether there is any deficiency in service or unfair trade practice from the side of the opposite parties to the complainant?
iii) If so, whether the complainant is entitled to get any relief from the side of the opposite parties?
iv) Costs of the proceedings if any?
6) The issues mentioned above are considered together and are answered as follows:
As per Section 2 (1) (d) of the Consumer Protection Act,1986, a consumer is a person who buys any goods or hires or avails of any services for a consideration that has been paid or promised or partly paid and partly promised, or under any system of deferred payment. The complainant had produced a copy of the policy document - Policy No. P/181200/01/2015/009982 dated 4/3/2015 issued by the opposite party to the complainant (Exhibit A-1). Hence, the complainant is a consumer as defined under the Consumer Protection Act, 1986 (Point No. i) goes against the opposite party.
In the present case, the complainant asserts claims of gross deficiency in service and unfair trade practices against the opposite party. The complainant entered into a contractual agreement with the opposite party for the acquisition of a Senior Citizen Red Carpet Insurance Policy. Subsequently, the complainant was admitted in Amritha Hospital for the purpose of receiving Pacemaker implantation and duly filed a claim with the opposite party. However, the opposite party only provided partial compensation in response to the claim. Dissatisfied with this partial compensation, the complainant opted to lodge an application before the Insurance Ombudsman, which was subsequently dismissed on grounds of merit. Consequently, the complainant has initiated the current complaint, seeking the outstanding balance of the claim amount, compensation, and the cost of the litigation.
The learned counsel for the complainant submitted that the complainant, is a policyholder of the opposite party, holding a Medi-claim policy known as Senior Citizens Red Carpet Insurance Policy. The policy was valid until February 26, 2016, and the complainant paid the premium as demanded by the company. The policy covered medical expenses except for excluded amounts mentioned in the policy document.
The complainant underwent a medical procedure for the implantation of a pacemaker at Amrita Institute of Medical Sciences and Research Centre. The total expenses incurred for the treatment were Rs. 2,34,257, for which the complainant submitted a claim to the opposite party.
Initially, there was no response from the opposite party, but after persistent follow-up, they considered the claim. However, the opposite party made some re-calculations and allowed only Rs. 80,441, without providing proper reasons for the reduction. It was discovered that the opposite party had made incorrect deductions, resulting in a difference of Rs. 32,090 from the promised claim amount of Rs. 1,12,531.
The complainant raised the issue with the opposite party, who refused to acknowledge their mistake and insulted the complainant. The complainant filed a complaint with the Insurance Ombudsman, but no relief on it was received for the complainant from there.
The opposite party reduced the claim to Rs.80,441, claiming that the complainant was not entitled to the full amount initially promised. This reduction and the deductions made by the opposite party were considered a deficiency in service and an unfair trade practice.
The opposite party's calculations were deemed incorrect and against the policy terms. The complainant, being a senior citizen, was taken advantage of by the company's executives. The opposite party's actions were seen as cheating and unfair.
The complaint argues that the opposite party's deduction calculations were incorrect, and the claim should have been allowed up to Rs. 1,50,000, without any co-payment deduction. The complaint also asserts that the limitations or principles of estoppel, acquiescence, abandonment, or res judicata do not apply in this case.
The complainant had raised objections to the deduction made by the opposite party, and the discharge voucher was signed under protest. The complainant maintains that their intentions are not malicious, and the allegations made in the complaint are based on factual grounds.
As a result, the complainant demands that the opposite party be held liable for the full claimed amount mentioned in the complaint.
The learned counsel for the opposite party submitted that the insurance policy contains specific exclusions and sub-limits for claims, including a co-payment requirement for pre-existing diseases. The complainant submitted a claim for medical treatment, but the opposite party determined that the complainant had a pre-existing condition and applied the applicable sub-limits and co-payment. The claim was settled accordingly, and subsequently, the complainant lodged a complaint with the Insurance Ombudsman, which was subsequently dismissed.
The opposite party argues that the complainant's acceptance of the settlement and encashment of the check renders them no longer a consumer and thereby renders the complaint baseless. They further accuse the complainant of filing the complaint with malicious intent to harass and gain illegal benefits. The opposite party denies any deficiency in service or unfair trade practices and asserts that they bear no further liability for payment or compensation. Consequently, they request the dismissal of the complaint with costs.
In view of the above facts and circumstances of the case, we are of the opinion that the Opposite Party is liable to compensate the complainant.
This amounts to unfair trade practices on the part of the manufacturers to escalate their sales and profit figures by thrusting the consumers to abandon the product and purchase a new one in its place.
We find the issues Nos. (ii) to (iv) are found in favour of the complainant for the serious deficiency in service that happened on the side of the opposite party. Naturally, the complainant had suffered a lot of inconveniences, mental agony, hardships, financial loss... etc. due to the negligence on the Opposite Party.
Hence the following orders are issued:
- The Opposite Party shall pay an amount of Rs.1,12,531/- (Rupees one lakh twelve thousand five hundred thirty one only) to the complainant
- The Opposite Party shall pay the complainant Rs.5,000/- (Rupees five thousand only) as compensation for mental agony and hardships suffered by him.
- The Opposite Party shall also pay to the complainant Rs.10,000/- (Rupees ten thousand only)towards the cost of the proceedings.
All the amount shall be paid by the opposite party within 30 days from the date of the receipt of a copy of this order. Failing which the amount ordered vide (i) and (ii) above shall attract interest @9.5% from the date of receipt of a copy of this order till the date of realization.
Pronounced in the Open Commission on this the 23rd day of June, 2023
Sd/-
D.B.Binu, President
Sd/-
V.Ramachandran, Member
Sd/-
Sreevidhia T.N., Member
Forwarded/by Order
Assistant Registrar
Senior Super
intendent
APPENDIX
COMPLAINANT’S EVIDENCE
Exhibit A-1. Copy of policy document - Policy No. P/181200/01/2015/009982 dated 4/3/2015.
Exhibit A-2. Discharge Summary dated 27/3/2015 issued from Amrita Institute of Medical Sciences and Research Centre.
Exhibit A-3. Bill No. IPF/IPB BC01/14/23736 dated 27/3/2015 with Annexures I and II.
Exhibit A-4. Bill Assessment Sheet dated 3/8/2015 issued by Star Health and Allied Insurance Co. Ltd.
Exhibit A-5. Bill Assessment Sheet dated 9/10/2015 issued by Star Health and Allied Insurance Co. Ltd.
Exhibit A-6. Award of the Insurance Ombudsman dated 5/2/2016.
Exhibit A-7. Notice of demand dated 26/10/2015.
Exhibit A-8. Postal receipt for sending the Notice of demand dated 26/10/2015.
OPPOSITE PARTY’S EVIDENCE
Exhibit A-1. Copy of policy document - Policy No. P/181200/01/2015/009982 dated 4/3/2015.
Exhibit A-2. Discharge Summary dated 27/3/2015 issued from Amrita Institute of Medical Sciences and Research Centre.
Exhibit A-3. Bill No. IPF/IPB BC01/14/23736 dated 27/3/2015 with Annexures I and II.
Exhibit A-4. Bill Assessment Sheet dated 3/8/2015 issued by Star Health and Allied Insurance Co. Ltd.
Exhibit A-5. Bill Assessment Sheet dated 9/10/2015 issued by Star Health and Allied Insurance Co. Ltd.
Exhibit A-6. Award of the Insurance Ombudsman dated 5/2/2016.
Exhibit A-7. Notice of demand dated 26/10/2015.
Exhibit A-8. Postal receipt for sending the Notice of demand dated 26/10/2015.
Despatch date:
By hand: By post
kp/
CC No. 172/2016
Order Date: 23/06/2023
