By Sri. A.S. Subhagan,  Member:

          This is a complaint  preferred under  Section 12(a) of the Consumer Protection Act 1986.

          2. Facts of the complaint:-  The complainant  had   taken  a medical insurance

policy named Family Health Optima Insurance Plan from the Opposite Parties on     24-12-2011 and the same had been renewed till 24-12-2018 and the Opposite Party No.2 had issued the renewed policy certificate to the complainant as per Policy No.P/181315/01/2019/003364. As per the terms and conditions of the policy, the Opposite Parties had assured to the Complainant to pay any hospital expenses incurred to the family members of the Complainant during the coverage of policy. The sum assured of the said policy was Rs.3,00,000/- and the policy period was 24-12-2018 to 23-12-2019. During the validity of the said policy the Complainant's son Eldhos Shaji was admitted in Aster Specialty Orthopedic Hospital Private Limited, Pantheerankavu, Calicut on 28-05-2019 for the treatment for Femur Fracture and he had undergone surgery and had discharged on 04-06-2019.

3. The Complainant intimated the hospitalisation of his son to the Opposite Parties. Subsequently the hospital authorities had applied to the Opposite Parties for cash less treatment for an amount of Rs.1,98,595/- but the Opposite parties had sanctioned only Rs.1,52,257/­ towards the hospital bills. Afterwards, the Complainant directly paid the balance bill amount of Rs.46,338/- to the hospital. Subsequently, the Complainant had approached the Opposite Parties and requested for reimbursement of total hospital expenses but it was rejected by the Opposite Parties stating some baseless excuses. The above said acts of the Opposite Parties are clear violation of the policy conditions and it caused heavy damages to the Complainant and the Opposite Parties are liable to pay the amount to the Complainant. The repudiation of claim on illegal ground amounts to deficiency in service on the part of Opposite Parties. The acts of the Opposite Parties had caused great inconvenience and hardships to the Complainant. The Opposite Parties are legally liable to pay the hospital expenses and compensation to the Complainant.

          4. Hence this complaint,  praying to pass an order directing the Opposite Parties to pay a sum of Rs.46,338/-  with 12% interest from 04.06.2019 to the Complainant  and also direct the Opposite  Parties to pay a sum of Rs.50,000/-  towards compensation and cost of this  Complaint to the Complainant. 

          5. The Complaint was registered and  notices were served upon the Opposite Parties for appearance.  The Opposite Parties entered appearance and joint version was filed by the Authorised  Signatory,  Mrs.  Padma Prabha. P,  Chief  Manager – Legal.

          6. Contents of  version filed  by the  Opposite Parties:- It is submitted that the Complainant had taken a Family Health Optima Insurance Policy commencing from 24/12/2011 covering his wife and three children and the same was renewed upto 23/12/2019 vide Policy No. P/181315/01/2019/003364 for a sum insured of Rs.3,00,000/-.  At the time of availing the policy the Complainant was supplied with the Terms and Conditions of the Policy. The Terms and Conditions of the Policy were explained to the Complainant at the time of proposing the policy and the same was served to the Complainant along with the Policy Schedule. Moreover, it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATAACHED".  It is submitted that the Opposite Parties received a pre-authorization request for cashless hospitalization from Aster Hospital, Kozhikode stating that the son of the Complainant was admitted at the hospital on 28/05/2019 and was provisionally diagnosed with Fracture Shaft of right femur and also forwarded the treatment records.

7. Based on the submitted documents/details, the Opposite Party had authorized an amount of Rs.1,52,257 and informed the hospital on 04/05/2019. After the treatment the patient was discharged on 04/06/2019.  After the discharge from the hospital, the Complainant had submitted claim form, bills and reports for the balance of the cashless of Rs.46,338/-. It is submitted that the total claimed amount is Rs.2,01,240/- and during reimbursement, the Complainant had not submitted the balance paid receipt of Rs.46,338/-. Hence the Opposite Parties had deducted Rs.24,125/- for not submitting the paid receipt and had paid the balance amount of Rs.2,420/-. It is submitted that the Opposite Party had processed the entire claim as per Policy Terms and Conditions and has considered the standard payable amount at the time of cashless and reimbursement. But, after receipt of the Complaint from this Hon'ble Forum, the Opposite Parties again reprocessed the claim and considered the standard admissible amount and hence the opposite party is ready to give the balance amount of Rs.24,125/- to the Complainant subject to the production of balance paid receipt of Rs.46,338/-. All other deductions were made as per Policy Terms and Conditions.

8. It is humbly submitted that even if this Hon'ble Forum finds any liability upon this Opposite Party, then the liability of the Opposite Party may be limited to Rs.24,125/-    subject to   the   production of   balance  paid   receipt of   Rs.46,338/-.

The Complainant is not entitled to any compensation or costs of the proceedings. The claim for compensation is unfounded and baseless and is only a figment of Complainant's imagination to make illegal gains for him. No mental agony of whatever nature has been caused as the bill has been settled by the Opposite Party in time. There is no deficiency in service from the side of the Opposite Parties and thus the Complainant has no cause of action.  

          9. Chief affidavit was filed by the Complainant,  documents Exts.A1 to A4 were marked from his side and he was examined as PW1.  Chief affidavit was  also  filed  by Balu. M,  Assistant Manager- Legal on behalf of the  Opposite Parties,  documents Exts.B1 to B4 were  marked  and he  was examined as OPW1.

          10. Commission perused the complaint,  version, affidavit filed,  documents marked and the oral evidences adduced by the Complainant and the Opposite Parties, 

the following points are raised by us for consideration.

1. Whether there has been any unfair trade practice/deficiency in service from the part of the Opposite Parties?
2. If so,  whether the Complainant has the right to get  compensation and cost  as prayed for?

11. Point No.1:-  It is the admitted fact that the  Complainant being a Family

Health Optima Insurance Policy Holder of the Opposite Parties had preferred a total insurance claim of Rs.2,01,240/-  of which an amount of Rs.1,52,257/-  had  pre-authorised by the Opposite Parties and the matter was informed to the Aster Hospital, Kozhikode  where the Complainants son was  admitted and treated.    After the treatment,  the patient was discharged on 04.06.2019.  After discharge from the hospital,  the Complainant had submitted claim form, bills and reports for the balance of Rs.46,338/-.  The allegation of the Complainant is that though he  had approached the Opposite Parties,  after directly paying the balance amount of Rs.46,338/-  to the hospital,   for reimbursement of  total hospital expenses,  it was rejected by the Opposite Parties stating some baseless excuses which amounts to deficiency in service from the part of the Opposite Parties.  The Opposite Parties had admitted that after discharge from hospital,  the Complainant had submitted claim form,  bills and reports for the balance of Rs.46,338/-.  Here,  the contention of the Opposite Parties is that the total claim amount was Rs.2,01,240/-  and during  reimbursement,  the Complainant had not submitted the balance paid receipt of Rs.46,338/-.  The Opposite Parties content that after receipt of this  Complaint, the Opposite Parties reprocessed the claim and considered the standard admissible amount and hence the Opposite Party is ready to give the balance amount of Rs.24,125/-  to the Complainant subject to the production of balance  paid receipt of Rs.46,338/-  and adds that all other deductions were made as per policy terms and conditions.  But in oral examination of OPW1,  in evidence, has stated as follows:-  “Professional fees Bbn 45,700/þ  cq]-bpsS bills  BWv In«n-bXv AXn- \n¶pw 18,595/-þ I¼\n less  sNbvXp.  CXv Ipd-¨Xv tUmIvSÀam-cpsS market rate  A\p-k-cn¨v Ipd-¨-Xm-Wv.  Ext.B1   tUmIvSÀam-cpsS  market rate    ImWn-Ã.    ICU  InS-¶-Xnsâ 5,000/þ cq]bpw I¼\n Ipd-¨p.  Cu 5,000/þ  cq]  Ipd-bv¡m³ ]äp-sa¶v Ext.B1   ImWnÔ.   In chief affidavit and version filed  by the Opposite Parties,  it has stated that the deductions are made as per Policy Conditions. On the other hand in oral  examination  OPW1 has deposed that the deduction of Rs.18,595/- towards professional charge of Doctors as per their market rate, and the deduction of Rs.5,000/-  towards  charge of ICU could not be seen in Ext.B1 policy conditions.  From this statement of OPW1  it is evident that the Opposite Parties had illegally deducted Rs.18,595 + Rs.5,000/- =23,595/-  from the hospital bills submitted by the Complainant.  During the time of arguments,  the Counsel  for the Complainant has argued that no such market rate of Doctors are fixed by any authority and the Opposite  Party has no right to fix any market rate of Doctors.  Professional charges of Doctors are the actual charges paid to the Doctors by the hospitals.  Accepting the arguments of the counsel for the Complainant  and the oral deposition of the OPW1,  we declare that fixing  of market rate of Doctors by the Opposite Parties is illegal and making  deduction in the hospital bills of the Complainant is not in good faith and against natural justice which is unfair trade practice/deficiency in service.  Therefore,  here there has been unfair trade practice/deficiency in service from the part of the Opposite Parties. The Opposite Parties have already admitted that  they are ready to pay Rs.24,125/-  as they have reprocessed the claim of the Complainant.  Considering  the facts of the case,  the Complainant has also the eligibility to get Rs.18,595 + Rs.5,000 = 23,595 which  the Opposite Parties had deducted towards  professional charges of Doctors and charges on ICU respectively.  That is,  the Complainant has the right to get  reimbursement of his claim towards hospital expenses  Rs.24,125 +23,595  = 47,720/- in addition to the cashless payment already made to the hospital.  But the amount  claimed by the Complaint is only   Rs.46,338/-.  The  Complainant affirms that all the bills with other documents have been submitted to the Opposite Parties for final settlement of his claim.  In  para seven of the version, the Opposite Party has admitted that “After the discharge from the hospital,  the Complainant had submitted  claim form,  bills and reports for the balance of the  cashless  amount”.  Hence,  we find  that why the Opposite Parties insist to produce the paid receipt of the amount  as it is a truth  that the patient under treatment in the hospital could  only be discharged on settling the hospital bills.  Here,  the Complainant  has declared that  he has settled the final bill in the hospital.  So,  in our view there is no basis for the demand of production of paid receipts from the Complainant by the Opposite Parties.  If the Opposite Party is badly in need of the paid receipts, they can seek clarification  regarding this  matter directly from the  hospital.  So, point  No.1 is proved against the Opposite Parties.

          12. Point No.2:-  As point No.1 is proved against the Opposite Parties the Complainant has the right to get compensation and cost from the Opposite Parties,  but the amount claimed  by the Complainant is seen exorbitant.

          In the result,  the Complaint is partly allowed and the Opposite Party is ordered to:-

1.  Reimburse Rs.46,338/- (Rupees Forty Six thousand Three hundred and Thirty Eight only) being the final claim amount to the Complainant,  together with interest @ 8% per annum from  04.06.2019,  the date on which the patient was discharged from the hospital.
2. Pay a compensation of Rs.20,000/-  (Rupees Twenty thousand only) to the Complainant for unfair trade practice/deficiency in service and
3. Pay an amount of Rs.5,000/-  (Rupees Five thousand only) as cost of this Complaint.

The above amounts shall be paid to the Complainant within one month from

the date of this order,  failing which  the amounts will carry interest @ 8% per annum from the date of this order.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Commission on this the 27^th day of September 2022.

Date of filing :27.02.2020.

                                                                        PRESIDENT :  Sd/-

                                                                        MEMBER    :  Sd/-

                                                                        MEMBER    :  Sd/-

APPENDIX.

Witness for the complainant:

PW1.          Shaji. M.V.                     Complainant

Witness for the Opposite Party:

OPW1.        Balu. M.                         Assistant Manager.

Exhibits for the complainant:

A1.    Policy Schedule.            

A2.    Copy of Discharge Summary.

A3.    Copy of Letter.                                             dt:04.06.2019.

A4.    Copy of Calculation Statement.                    dt:04.06.2019.

Exhibits for the Opposite Party:

B1.    Copy of Family Health Optima Insurance  Policy- Schedule.

B2.    Copy of Request for Cashless Hospitalisation for  Medical

           Insurance  Policy.

B3.    Copy of Authorization for Final Enhancement of amount.         dt:04.06.2019.

B4.    Copy of Bill assessment sheet.