Punjab

Ludhiana

CC/19/524

Charanjeet Kaur - Complainant(s)

Versus

Star Health and Allied Insurance - Opp.Party(s)

Maninder Khara adv

29 Jul 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 524 dated 08.11.2019.                                                        Date of decision: 29.07.2022.

 

Mrs. Charanjeet Kaur aged about 65 years, R/o. H. No.4, Street No.4, near Jay Rath Dharamshala, Chander Nagar, Haibowal Kalan, Ludhiana.                                                                                                                 ..…Complainant 

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1. Star Health and Allied Insurance Co. Ltd., No.15, Sri Balaji Complex, 1^st Floor, Whites Lane, Royapettah, Chennai Through its Managing Director/Authorized Person.   
2. Star Health and Allied Insurance Co. Ltd., having Branch office at No.3369, 4^th Floor, Sandhu Tower-II, Ferozepur Road, Ludhiana-141001 Through its Branch Manager.                                                                                                                                             …..Opposite parties 

Complaint under Section 12 of the Consumer Protection    Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Maninder Khara, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                In brief, the case of the complainant is that she obtained Senior Citizen Red Carpet Health Insurance Policy from the OPs bearing No.P/161114/01/2017/006097 which was valid from 19.09.2016 to 18.09.2017. The sum assured under the policy was Rs.10,00,000/-. In the month of October 2016, the complainant was diagnosed with the problem of CA-Thyroid  by the doctors of Ludhiana Mediways Hospital. The complainant got herself treated from the said hospital and further got treatment from Dayanand Medical College and Hospital and Mohandai Oswal Hospital from time to time. The complainant also remained admitted in Mohandai Hospital for her treatment from time to time. The complainant is, therefore, entitled for reimbursement of the expenses incurred by her on her treatment. The complainant lodged the claim with the OPs along with all the relevant documents. However, the claim submitted by the complainant for expenses incurred by her at Ludhiana Mediways Hospital was reimbursed after making deduction whereas the expenses incurred by her at Mohandai Oswal Hospital  were not reimbursed. The complainant vide letter dated 17.12.2018 addressed to OP2 made a request to reimburse an amount of Rs.89,110/- against the expenses incurred at Mohandai Oswal Hospital.  The complainant further incurred a sum of Rs.9360/- on her treatment at Dayanand Medical College and Hospital. Thus, the  complainant was entitled to be reimbursed an amount of Rs.98,470/-. The OPs, however, vide letter dated 29.03.2019 refused her to reimburse the amount on the grounds that the original bills were not submitted. As a matter of fact, some of the bills and receipts were lost and the intimation in this regard was sent to the OPs. The complainant again vide letter dated 05.04.2019 sent original bills dated 24.12.2016 for Rs.20,200/-, bill dated 09.01.2017 of Rs.28,500/- and bill dated 03.10.2018 for R.5,000/-. The remaining bills and receipts were sent after getting duplicate copy issued from the hospital authorities which were duly attested by the doctors and the hospital authorities. However, the Ops vide letter dated 22.04.2019 refused to reimburse the said expenses on the pretext of non-submission of original bills. This amounts to deficiency of service on the part of the OPs. In the end, it has been requested that the OPs be directed to reimburse the amount of Rs.98,470/-  incurred by the complainant on her treatment along with interest @12% per annum and further the OPs be made to pay Rs.50,000/- for deficiency of service and Rs.15,000/- on account of legal expenses.

2.                The complaint has been resisted by the OPs. In the joint written statement filed on behalf of the OPs, it has been, inter alia, pleaded that the complaint is not maintainable. According to the OPs, the claim of the complainant already stands settled for a sum of Rs.44,791/-  which was paid vide DD No.146298 dated 20.02.2019 for a sum of Rs.42,708/-  and the balance sum of Rs.2083/- was paid through NEFT on 10.05.2019. The said amount was accepted voluntarily by the complainant without any protest. Having accepted the amount of Rs.44,791/-, the complainant does not remain a consumer any more. Moreover, as per condition No.5 of the policy, the policy is subject to co-payment of 50% of each and every claim arising out of pre-existing disease as defined by the policy holder and 30% of each and every claim for all other claims which are to be borne by the insured. According to the OPs, the claim was reported in the first year of the inception of the policy. The complainant submitted a claim of Rs.63,320/- in respect of her hospitalization in Ludhiana Mediways Hospital, Ludhiana on 21.11.2016 with diagnoses of metastatic spine L2 with primary CA thyroid. Based on the submitted documents an amount of Rs.42,708/- was settled on 20.02.2019. The reasons for deductions were communicated to the complainant. According to the OPs, the complainant had not submitted break up for medicine and investigation charges. Therefore, only 90% of the charges were allowed. Similarly, the charges for extra nursing charges, dietician charges, bath tower and admission charges are not payable and a sum of Rs.2030/- was deducted.  As per condition No.5, the policy is subject to co-payment of 50% of each and every claim arising out of pre-existing disease and 30% of each and every claim for all other claims a sum of Rs.18,303/- was deducted under 30% co-pay.

3.                It is further alleged that the insured submitted pre and post hospitalization bills for reconsideration. On scrutiny, it was found that the insured had not submitted the original final bill and the claim was repudiated vide letter dated 22.04.2019. The complainant again issued original receipt with request for consideration based on which an amount of Rs.2083/- was settled and paid to the complainant through NEFT on 10.05.2019 as per the terms and conditions of the policy. The complainant again submitted a claim of Rs.9360/-  which was rejected vide letter dated 30.05.2019 since the complainant had not submitted the original bill. The complainant had also submitted the expenses of Rs.9360/- towards pre hospitalization and Rs.89,110/- towards post hospitalization. However, as per the policy, pre hospitalization expenses of Rs.9360/- were not payable. Further, as per the coverage Clause A, a sum equivalent to 7% of the hospitalization expenses incurred comprising of nursing charges, surgeon/consultant fees, diagnostic charges, medicines and drugs is payable subject to a maximum of Rs.5,000/- per occurrence towards post hospitalization. Thus, the OPs settled and paid a sum of Rs.2083/- being 7% of the hospitalization after deducting an amount of Rs.87,027/-. In this manner, an amount of Rs.44,791/-  was the maximum payable amount which had already been paid. The deduction was already conveyed to the complainant. The OPs have processed the claim as per the terms and conditions of the policy which were accepted by the complainant voluntarily and without any protest. Thus, there has been no deficiency of service on the part of the OPs. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

4.                In evidence, the complainant submitted her affidavit as Ex. CW along with documents Ex- C1 to Ex- C12 and closed the evidence.

5.                On the other hand, learned counsel for the OPs tendered affidavit Ex. RA of Sh. Rajiv Jain, Chief Manager of the OPs along with documents Ex. R1 to Ex. R8 and closed the evidence.

6.                We have heard the counsel for the parties and gone through the record.

7.                During the course of arguments, the counsel for the complainant has argued that the complainant has lost the original bills of the amount of Rs.98,000/- but the duplicate bills were duly submitted but the OPs have paid only a sum of Rs.2309/- which is illegal and arbitrary and not as per terms and conditions of the policy. The OPs are, therefore, liable to reimburse the amount of Rs.98,470/- with interest and charges, as prayed for in the complaint.

8.                On the other hand, the counsel for the OPs has argued that the claim for Rs.63,320/- was lodged by the complainant in the first year of the policy and against the said claim, a sum of Rs.44,791/- was paid after deducting 30% of the expenses as per terms and conditions of the policy. As regards the pre and post hospitalization charges claimed by the complainant, only a sum of Rs.2309/-  was payable which has been duly paid. Thus, there is no deficiency of service on the part of the OPs.

9.                We have thoughtfully considered the above contentions of the counsel for the parties and have gone though the record carefully.

10.              Admittedly, the complainant herself did not submit the original bills as some of the bills stated to have been lost. However, it is well settled that the insurance company can reimburse only on the basis of original bills and if the insured has lost the original bill, the OP company cannot be blamed.

11.              Secondly, it has been rightly pointed out by the counsel for the complainant that the complainant lodged claim of Rs.63,320/- in the very first year of the policy and as against the said claim, a sum of Rs.42,708/- was paid vide DD No.146298 dated 20.02.2019. In this regard, the counsel for the OPs has pointed out that as per the terms and conditions of the policy known as Senior Citizen Red Carpet Health Insurance Policy, the policy holder is to contribute/bear expenses of 50% for all pre-existing disease and 30% for all other claims. In respect of the claim of Rs.63,320/- also, the payment of Rs.44,791/- has been made after deducting 30% as per the terms and conditions of the policy.

12.              So far as the pre and post hospitalization expenses are concerned, as per the terms and condition enshrined in the policy Ex. R1, no pre hospitalization expenses are admissible for payment except ambulance charge of Rs.600/- per hospitalization subject to a maximum of Rs.1200/- per policy period. So far as post hospitalization charges are concerned, as per policy Ex. R1 only a sum equivalent to 7% of the hospital expenses subject to maximum of Rs.5000/- pre occurrence are payable towards post hospitalization expenses. Accordingly a sum of Rs.2083/- was settled and paid, being 7% of the total amount of hospitalization excluding room rent. Thus, all the claims admissible to the complainant as per terms and conditions of the policy have already been paid to her. Thus, it cannot be said to be a case of deficiency of service on the part of the OPs.

13.              As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

14.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:29.07.2022.

Gobind Ram.

Charanjeet Kaur Vs Star Health Allied Insurance                      CC/19/524 

Present:       Sh. Maninder Khara, Advocate for complainant.

                   Sh. Rajeev Abhi, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:29.07.2022.

Gobind Ram.