Haryana

Karnal

CC/517/2021

Ravi Chauhan - Complainant(s)

Versus

Star Health And Allied Insurance Company Limited - Opp.Party(s)

Deepak Sachdeva

12 Aug 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                          Complaint No. 517 of 2021

                                                          Date of instt.24.09.2021

                                                          Date of Decision 12.08.2022

 

Ravi Chauhan son of late Shri Sham Lal, resident of village Daniyalpur District Karnal, age 26 years (Aadhar card no.8389 5153 5802).

 

                                                 …….Complainant.

                                              Versus

 

1.     Star Health and Allied Insurance Co. Ltd. through its Manager, SCF no.137, 2^nd floor, above ICICI Bank, Sector-13,Karnal.

 

2.     Grievance Redressal Officer, Corporate Grievance Department,

        Star Health and Allied Insurance Co. Ltd., 1, New Tank Street, Vailiuvar Kottam High Road, Nungambakkam, Chennai-600034.

        IInd Address

        Grievance Redressal Officer, Corporate Grievance Department,

        Star Health and Allied Insurance Co. Ltd., MKM Chambers, 5^th floor, no.42 Kodambakkam High Road, Nungambakkam, Chennai-600034.

                                                                    …..Opposite Parties.

 

      Complaint u/s 35 of the Consumer Protection Act, 2019

 

Before   Sh. Jaswant Singh……President.       

      Sh.Vineet Kaushik ………..Member

      Dr. Rekha Chaudhary…..Member

 

 Argued by: Shri Deepak Sachdeva, counsel for the complainant.
                    Shri Naveen Khetarpal, counsel for the OPs.

                                        

                (Jaswant Singh President)

ORDER:                    

 

                        The complainant has filed the present complaint u/s 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant had got insured from OPs, vide policy no.P/211114/01/2021/010661, valid from 06.01.2021 to 05.01.2022 for a sum assured of Rs.5,00,000/ and paid regular premium against the said policy. In July, 2021 the complainant suddenly started vomiting and fever and then complainant visited to the Tagore Hospital, Karnal where after various tests complainant came to know that he is suffering from Typhoid/Acute Gestro Enteritis disease. Accordingly, complainant was got admitted in the hospital on 07.07.2021 and was discharged on 12.07.2021. Complainant incurred approximately Rs.59114/-on his treatment. Thereafter, complainant many times gave intimation to OPs and submitted all the relevant documents alongwith copy of bills, treatment record etc. then OPs gave the assurance that OPs will release the claim amount against the said policy. The complainant has visited the OPs to pay the compensation as per the policy but OPs has paid only Rs.44336/- and remaining amount has not been paid by the OPs after repeated requests. Then complainant sent a legal notice dated 26.08.2021 and 27.08.2021 to the OPs but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Policy Covering Mr. Ravi Chauhan-self, Mrs. Jyoti Devi-spouse Shreya and Reyansh Chauhan-dependant child for the sum insured of Rs.5,00,000/-, vide policy no.P/211114/01/2021/010661 for the period from 06.01.2021 to 05.01.2022. The terms and conditions of the policy were explained to the complainant at the time of proposing the policy and same was served to the complainant alongwith the policy schedule. Moreover, it is clearly stated in the policy schedule the insurance under this policy is subject to condition, clauses, warranties, exclusion etc. The policy is contractual in nature and claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. It is further pleaded that the complainant has submitted the claim for reimbursement of Rs.59114/-, based on the submitted claim documents, the claim was processed and an amount of Rs.44336/- was approved and paid to insured on 23.08.2021. The claim was again reviewed and considered for settlement for an amount of Rs.7381/- was paid to insured on 02.10.2021.

Reason for deduction

        The insured has not submitted amount wise breakup of bill of lab charges. Hence, 20% of the same i.e. 430 was deducted.  

        The charges pertaining to medicines of Rs.5967/-was disallowed since the bill amount was not clear.

        As per the other excluded expenses of the policy, file charges are not payable, hence an amount of Rs.1000/- are not payable.

        Total Claimed amount:       Rs.59114/-

        Deduction                          Rs. 7397/-

        Total Amount settled          Rs.51,717/-

As per complaint insured has demanded Rs.14,778/-. However, out of which Rs.7381/- is already reconsidered and paid. Remaining Rs.7397/- is not payable as terms and conditions of policy. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied by the OPs and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of renewal policy bond from 06.01.2021 to 05.01.2022 and 23.12.2019 to 22.12.2020 Ex.C1 and Ex.C2, policy bond dated 18.12.2018 to 17.12.2019 Ex.C3, copy of policy card Ex.C4, copy of legal notices Ex.C5 and Ex.C6, postal receipt Ex.C7, copy of Aadhar card Ex.C8, copy of claim form Ex.C9, copy of authorization letter Ex.C10, copy of claim form part B by hospital Ex.C11, copy of OPD slip Ex.C12, copy of discharge summary Ex.C13, copy of medicines bills and hospital bills Ex.C14 to Ex.C24, Ex.C36 and Ex.C37, copy of OPD slip dated 07.07.2021 Ex.C25, copy of blood test reports Ex.C26 to Ex.C30, copy of treatment record Ex.C31 to Ex.C35, copy of bill assessment sheet Ex.C36 and closed the evidence on 25.01.2022 by suffering separate statement.

5.             On the other hand, learned counsel for OPs has tendered into evidence affidavit of Sumit Kumar Manager, Senior Manager Ex.RW1/A, copy of proposal form Ex.R1, copy of letter to insured Ex.R2, copy of insurance policies Ex.R3 to Ex.R5, copy of terms and conditions of the insurance policy Ex.R6, copy of claim form Ex.R7, copy of discharge summary Ex.R8, copy of bills Ex.R9, copy of calculation sheet Ex.R10, copy of bill assessment sheet Ex.R11, copy of IRDA guidelines Ex.R12 and closed the evidence on 06.06.2022 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that complainant had purchased a health insurance policy from the OPs. In the month of July, 2021 the complainant suddenly started vomiting and fever and then he visited to the Tagore Hospital, Karnal where after various tests complainant came to know that he is suffering from Typhoid/Acute Gestro Enteritis disease. Accordingly, complainant was got admitted in the hospital on 07.07.2021 and was discharge on 12.07.2021 and spent Rs.59114/-on his treatment. Thereafter, complainant submitted all the relevant documents alongwith copy of bills, treatment record etc. with the OPs for reimbursement of the claim but OPs has paid only Rs.44336/- and remaining amount has not been paid by the OPs after repeated requests and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for OPs, while reiterating the contents of written version, has vehemently argued that the complainant has submitted the claim for reimbursement of Rs.59114/- The claim was processed and an amount of Rs.44336/- was approved and paid to insured on 23.08.2021. The claim was again reviewed and considered for settlement for an amount of Rs.7381/- was paid to insured on 02.10.2021. Remaining Rs.7397/- is not payable as terms and conditions of policy and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant has taken Family Health Optima Insurance Policy from the OPs, valid from 06.01.2021 to 05.01.2022. It is also admitted that complainant had taken treatment from Tagore Hospital, Karnal. It is also admitted that complainant has submitted the bill of Rs.59114/- with the OPs. It is also admitted that an amount of Rs.44336/- was paid to the complainant on 23.08.2021. It is also admitted that claim was again reviewed and an amount of Rs.7381/- was paid to the complainant on 02.10.2021.

11.           Now remaining is dispute is only for the Rs.7397/-. As per the version of the complainant, OPs have wrongly deducted the said amount. Rather OPs were legally bound to pay the said amount. On the other hand, as per the version of the OPs the insured has not submitted amount wise breakup of bill of lab charges. Hence, 20% of the same i.e. 430 was deducted.      The charges pertaining to medicines of Rs.5967/-was disallowed since the bill amount was not clear. As per the other excluded expenses of the policy, file charges are not payable, hence an amount of Rs.1000/- are not payable.

        Total Claimed amount:       Rs.59114/-

        Deduction                          Rs. 7397/-

        Total Amount settled          Rs.51,717/-

As per complaint insured has claimed the remaining claim amount of Rs.14,778/-. However, out of which Rs.7381/- has already paid. Remaining amount of Rs.7397/- is not paid by the OPs on the abovementioned grounds.

12.           The onus to prove its case lies upon the OPs but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. OPs have also failed to prove that as to why the remaining claim amount was not payable. In view of the above, we are of the considered view that OPs have harassed the complainant to such an extent of compelling him to file the present complaint. Thus, the act of the OPs amounts to deficiency in service and unfair trade practice.

14.           In view of the above discussion, we allow the present complaint and direct the OPs to pay Rs.7397/-to the complainant with interest @ 9% per annum from the date of refusal of the claim till its realization. We further direct the OPs to pay Rs.10,000/- to the complainant on account of mental agony and harassment and  towards the litigation expenses. This order shall be complied within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:12.08.2022                                                                     

                                                                 President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)    

                     Member                    Member