Haryana

Karnal

CC/61/2021

Subhash Chand - Complainant(s)

Versus

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

Satyajit Singh

14 Jun 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES EDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 61 of 2021

                                                        Date of instt.01.02.2021

                                                        Date of Decision:14.06.2023

 

Subhash Chand son of Shri Ram Saran, resident of village Dabarthala, Tehsil Nilokheri, District Karnal, aged about 45 years. Aadhar card no.4070 8535 8089.

 

                                               …….Complainant.

                                              Versus

 

Star Health and Allied Insurance Company Limited, having its branch office at SCO no.104, 1^st floor, Mugal Canal, Karnal.

 

                                                                      …..Opposite Party.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary……Member

          

 Argued by: Shri Shyam Singh, counsel for the complainant.

                    Shri Naveen Khetarpal, counsel for the OP.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased a health insurance policy from the OP, vide policy no.P/211123/01/2020/006121, valid from 09.02.2020 to 08.02.2021. The complainant was suffering from Pneumonia and he was admitted in the Park Hospital, Karnal on 17.02.2020 and was discharged on 23.02.2020. The hospital authorities made the bill of Rs.74065/-. The entire treatment of complainant was covered under the abovesaid policy but OP paid only an amount of Rs.62300/- and made deduction of Rs.11765/- in an illegal and unlawful manner and as such said payment was to be made by the complainant to the OP from his own pocket. After discharge from the hospital, complainant lodged his claim of Rs.11,765/- with the OP but OP started postponing the matter on one pretext or the other lastly refused to pay any amount to the complainant. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Policy covering Mr. Subhash Chand and Sharda Rani spouse and Rubal as dependent child for the sum insured of Rs.5,00,000/-, vide policy no. no.P/211123/01/2020/006121, valid from 09.02.2020 to 08.02.2021. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and same served to the complainant alongwith policy schedule. The insured preferred claims in the 3^rd year of the FHO policy. The insured requested for cashless authorization, based on the submitted cashless documents, the claim was processed and an amount of Rs.62,300/- was approved and paid to hospital deducting an amount of Rs.11765/-. The reasons for deductions are:

.       Thus, as per the investigation the room rent of the hospital at the time of availing claim is Rs.3500/-, however, the hospital has charged an amount of Rs.4000/- per day, hence deducted an amount of Rs.1500/- (500* 3 days). However, the insured has not submitted receipt for reimbursement, if submitted the same may be considered.

.       As per the other excluded expenses no.72 the expenses irrelevant to the present diagnosis is not payable. Hence, the investigation charges towards Rsb, ECG, ECHO and USG for a amount of Rs.5750/- was deducted.

.       As per the other excluded expenses, OXYGEN Allowed, part of ICU Separately Not Payable, hence an amount of Rs.2600/- as deducted.

.       As per the other excluded expenses, the charges towards admission (no.70) and Diet (no.105) charges deducted, which is not payable. Hence, an amount of Rs.300/- was deducted.

The insured submitted the claim for Reimbursement of pre and post hospitalization and the same was approved for Rs.2671/- was paid to insured through N291201279126691 on 17.10.2020. Therefore, the payable claim of the complainant has already been paid, as per terms and conditions of the policy. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.C1, copy of insurance policy Ex.C2, copy of hospital bills Ex.C3 and closed the evidence on 09.05.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of terms and conditions of the Insurance policy Ex.R1, copy of insurance policies Ex.R2 to Ex.R4, copy of details of policyholder Ex.R5, copy of request for cashless hospitalization for medical insurance policy Ex.R6, copy of patient detail Ex.R7, copy of query letter Ex.R8, copies of cashless letters Ex.R9 and Ex.R10, copy of discharge summary Ex.R11, copy of bill assessment sheet Ex.R12, copy of hospital bills Ex.R13, copy of claim  form Ex.R14, copy of bill assessment sheet Ex.R15, copy of IRDA guidelines Ex.R16 and closed the evidence on 19.12.2022 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 the complaint, has vehemently argued that complainant purchased a health insurance policy from the OP. Complainant was suffering from Pneumonia and he was admitted in the Park Hospital, Karnal on 17.02.2020 and was discharged on 23.02.2020. The complainant spent Rs.74065/- on his treatment. Complainant lodged the claim with the OP for reimbursement of the said amount but OP paid only Rs.62300/- and made deduction of Rs.11765/- without any cogent reason and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that the insured availed Family Health Optima Insurance Policy from the OP. The insured requested for cashless authorization, the claim was processed and an amount of Rs.62,300/- was approved and paid to hospital after deducting an amount of Rs.11765/- as per terms and conditions of the policy and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant purchased Family Health Optima Insurance Policy from the OP, covering complainant himself, Sharda Rani spouse and Rubal as dependent child for the sum insured of Rs.5,00,000/- for the period from 09.02.2020 to 08.02.2021. It is also admitted that complainant was admitted in the Park Hospital, Karnal on 17.02.2020 and discharge on 23.02.2020. It is also admitted that complainant spent Rs.74065/- on his treatment.

11.           On receipt of cashless documents, the claim was processed by the OP and an amount of Rs.62300/- paid to the hospital, OP has deducting an amount of Rs.11,765/- as per terms and conditions of the Insurance policy Ex.R1. The reasons for deduction of the said amount, which are reproduced as under:

.       As per the investigation the room rent of the hospital at the time of availing claim is Rs.3500/-, however, the hospital has charged an amount of Rs.4000/- per day, hence deducted an amount of Rs.1500/- (500* 3 days). However, the insured has not submitted receipt for reimbursement, if submitted the same may be considered.

.       As per the other excluded expenses no.72 the expenses irrelevant to the present diagnosis is not payable. Hence, the investigation charges towards Rsb, ECG, ECHO and USG for a amount of Rs.5750/- was deducted.

.       As per the other excluded expenses, OXYGEN Allowed, part of ICU Separately Not Payable, hence an amount of Rs.2600/- as deducted.

.       As per the other excluded expenses, the charges towards admission (no.70) and Diet (no.105) charges deducted, which is not payable. Hence, an amount of Rs.300/- was deducted.

 

The said deduction has been made by the OP as per terms and conditions of the insurance policy. OP has already paid an amount of Rs.62,300/- to the complainant. Moreover, complainant submitted the claim for reimbursement of pre and post hospitalization and the same was approved for Rs.2671/- and was paid to the complainant on 17.10.2020.

12.           Thus, in view of the above discussion, the present complaint is devoid of any merits and same deserves to be dismissed and same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:14.06.2023      

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

                (Vineet Kaushik)        (Dr. Rekha Chaudhary)      

                      Member                        Member