West Bengal

Birbhum

CC/70/2023

Kartick Chakraborty - Complainant(s)

Versus

Aditya Birla Health Insurance Co Ltd - Opp.Party(s)

Amit Dutta

28 Jun 2024

ORDER

Shri Sudip Majumder- President-in-Charge.

            The complainant/petitioner files this case U/S 35of Consumer Protection Act, 2019. The fact of the case in brief is that one Kartick Chakraborty aged about 43 years, at present resident Suri Dangalpara,Ward No 15, P.O. and P.S.- Suri,  District-Birbhum who purchased a Health Insurance Policy from the  OP being Policy No. 21-21-9090215-00 which is valid till the midnight of 30/12/2022 and by this way the complainant/insured became a consumer/customer of the OP i.e. Insurance Company.

            The complainant Kartick Chakraborty along with his wife Purnima Chakraborty and two daughters namely Palock Chakraborty and Pallabi Chakraborty are the insured under the aforesaid policy and the policy was valid up to 30/12/2022 and sum assured Rs. 5,00,000/-.

It is the further case of the complaint that the insured Kartick Chakraborty was admitted on 11/07/2022 at Durgapur City Hospital and Clinic Pvt. Ltd. with severe weakness, LBP, Fever, Cough, Vomiting, Diminished appetite and he was diagnosed Covid 19 (+ve). And after completion of treatment he was discharge on 18/07/2022 from the hospital.

It is the next case of the complaint that the insured incurred expenses for his treatment amounting to Rs. 66,509/-. That the complainant lodged claim before the OP insurance company as he was covered under the aforementioned insurance policy for health insurance and he submitted all the treatment papers along with bill and money receipt in connection with his treatment vide claim ID: 1112285043198.

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It is the specific case of the complaint that the OP insurance company repudiated the claim of the complainant vide letter dated 18/07/2022 on flimsy ground. That the ground of repudiation of the policy is given hereunder- “On scrutiny of the documents it has been observed that all the parameters of patient is in normal limit, and patient can be treated on home isolation basis hence denied. And hence we are unable to approve the Preauthorisation request.”

            Hence, after finding no other alternative the complainant is compelled to file this complaint before this Forum/Commission for proper relief and prays for:

1. To pass an order directing the OP to pay Rs. 66,509/- as insurance claim.
2. To pass an order directing the OP to pay interest @12% P.A. on Rs. 66,509/- since 18/07/2022 till realization of the claim.
3. To pass an order directing to OP to pay Rs. 20,000/- as litigation cost.
4. Other relief/reliefs.

The OP insurance company did not appear inspite of receipt of notice and as such the case has already run  exparte against OP vide order No. 04, dated 24/07/2023.

            The complainant examined himself as P.W-1 and submitted certain document in support of his case.

            As the case was hard exparte the entire evidence of the complainant was unchallenged.

            The complainant submitted written notes on argument (W/N/A). Some documents have also been filed by the complainant’s side and those are compared with original documents. Thereafter, Ld. Advocate for the complainant made oral argument in support of his case.

Heard Ld. advocate for complainant.

 Considered.

Perused all the documents.

Points for determination/Issues

1.  Whether the complainant is a consumer as per definition of the term ‘Consumer’ of the C.P Act. ?
2. Whether this Commission has jurisdiction to try this case?
3. Whether there is any deficiency in service on the part of the Ops?
4. Whether the complainant is entitled to get any other relief or reliefs as prayed for?

 

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Decision with reasons

Point No. 1:

            In this case, the complainant purchased a Health Insurance Policy from the OP being Policy No. 21-21-9090215-00  on payment of proper fees and this policy is valid till the midnight of 30/12/2022. Thus the complainant is a consumer under the OP Insurance Company and the OP Insurance Company is the service provider. Hence, the complainant is a consumer as per Sec. 2(7)(ii) of the Consumer Protection Act, 2019.

Point No. 2:

            In this case, the cause of action arose from 18/07/2022. The case has been filed on 25/05/2023 and as such it can be said that the complainant has been filed this case within the statutory period of the C.P. Act, 2019 and as such the instant complaint is not barred U/S 69(1) of the C.P. Act, 2019.

Pecuniary Jurisdiction of this District Commission as per Notification No. G.S.R. 892(E). dated 20^th December, 2022 by Consumer Affairs Department, Govt. of India, New Delhi i.e. Rs. 50 lakh.

That the complainant is a present resident of Suri Dangalpara,Ward No 15, P.O. and P.S.- Suri, Dist.- Birbhum, W.B. which is under the Territorial Jurisdiction of this District Commission as per Sec. 34(2) of C.P. Act, 2019.

            Hence, this Commission has Pecuniary Jurisdiction as well as Territorial Jurisdiction on the present issue.

Point No. 3:

It appears from the documentary evidence as available in the case record that the complainant was admitted in Durgapur City Hospital & Clinic Pvt. Ltd. on 11/07/2022 under Dr. Dwipen Kr. Roy for treatment of severe weakness, LBP, Fever, Cough, Vomiting, Diminished appetite and also diagnosed Covid 19 (+ve). He was discharge on 18/07/2022 and his legitimate claim was Rs.66,509/-.

But, the OP insurance company repudiate the claim of the complainant vide letter dated 18/07/2022 on flimsy ground. That the ground of repudiation of the policy is given hereunder- “On scrutiny of the documents it has been observed that all the parameters of patient is in normal limit, and patient can be treated on home isolation basis hence denied. And hence we are unable to approve the Preauthorisation request.”

From the above discussion, this Commission is of the view that the insured/complainant was admitted as per instruction of the doctor of the said hospital and the doctor thought need of admission of the patient. But the OP insurance company stated in their repudiation letter as “…….patient can be treated on home isolation basis hence denied…….”.This is a vexatious one. A patient cannot be admitted to the hospital as per advice of the insurance company. The doctor will decide whether the patient needs admission to the hospital. The insurance policy was valid upto the midnight of 30/12/2022 and the complainant was admitted in the said hospital on 11/07/2022. The insurance claim of the

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complainant is within the limit of the sum assured. So, the complainant is entitled to get his legitimate insurance claim.

This Commission is of the view that the cause shown by the OP for repudiation of the said claim is baseless and vexatious one.

It is proved beyond all reasonable doubt that there is/was deficiency in service as per Sec. 2(11) of the C.P. Act, 2019 as well as unfair trade practice as per Sec. 2(47) of C.P. Act, 2019 on the part of the OP.

Hence, from the above discussion it is proved that the complainant could be able to prove his case beyond all reasonable doubts.

• In ICICI Bank Ltd. Rep. By Its. vs. Mr. Kateka Sudhakar,S/O K.J… on 5 March, 2018 the Hon’ble State Commission, Hyderabad stated in para 16 as follows:-

“16. The Supreme Court held that the compensation to be awarded is to be fair and reasonable.          In Charan Singh vs Healing Touch Hospital and others 2000SAR(Civil) 935 the Apex Court stressed the need of balancing between the compensation awarded recompensing the consumer  and the change it brings in the attitude of the service provider. The Court held While quantifying damages , consumer forums are required to make an attempt to serve ends of justice so that compensation is awarded, in an established case, which not only serves the purpose of recompensing the individual, but which also at the same time aims to bring about a qualitative change in the attitude of the service provider. Indeed calculation of damages depends on the facts and circumstances of each case. No hard and fast rule can be laid down for universal application. While awarding compensation, a Consumer Forum has to take into account all relevant factors and assess compensation on the basis of accepted legal principles, on moderation. It is for the Consumer Forum to grant compensation to the extent it finds it reasonable, fair and proper in the facts and circumstances of a given case according to established judicial standards where the claimant is able to establish his charge.”

            Keeping the view of the Hon’ble Apex Court in mind in respect of the manner of the compensation and quantum of compensation as per fact and circumstances of the present case this Commission is of opinion that in the instant case the loss of the complainant would be served in just way in terms of money and the quantum of compensation will be just and proper if the OP insurance company is directed to pay Rs. 5,000/-(Five thousand only) to the petitioner or complainant as additional compensation as against mental agony and harassment to the complainant.

            Further, it is necessary to mention that the OP Insurance Company repudiated the legitimate claim of the complainant on the strength of one baseless, manufactured, vexatious opinion which was made by the OP in their repudiation letter dated 18/07/2022 and stated as “…….patient can be treated on home isolation basis hence denied…….”. It appears to us the act of the OP Insurance Company is unfair trade practice as per the C.P. Act. That’s why OP should be saddled with exemplary cost of Rs. 2000/-(Two thousand only) for its deliberate unfair trade practice.

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            In Chengalrayan Cooperative Sugar Mills Vs. Oriental Insurance Co. Ltd. & Anr. (2000) 10 SCC 213 it was held that “Interest ought to have been awarded from the date on which the claim was filed before the Forum.”

• In Krishna Bhagya Jala Nigam Ltd. Vs. G. Harishchandra Reddy & Anr. (2007) 2 SCC 720 it was held that “Only 9% interest be awarded on refund matter.”

            In the instant case as per view of the Hon’ble Apex Court in several cases the interest will be given @ 9% p.a. calculating from the date of filing of this case.

Hence, it is,

            O R D E R E D,

                                        that the instant C.C. Case No. 70/2023 be and the same is allowed

without contest with cost. The OP Insurance Company is directed to pay the insurance claim of                Rs. 66,509/- (Sixty six thousand five hundred nine only) to the complainant along with interest @ 9% per annum calculation on and from 25/05/2023 (i.e. from the date of filing of this case) till realization.

The OP Insurance Company is also directed to pay compensation of Rs. 5,000/- (Five thousand only) to the complainant/petitioner as against mental agony and harassment to the complainant and        Rs. 5000/- (Five thousand only) as the cost of litigation to the complainant.

The OP Insurance Company is also directed to pay the exemplary cost of Rs. 2000/-(Five

thousand only) to the Consumer Legal Aid Accounts, DCDRC, Birbhum, Account No. 34041754378, IFSC Code. SBIN0000191, State Bank of India, Suri Branch.

The entire decree will be complied by the OP No. 1 within 45 (Forty five) days from this date of

order, in default the complainant is at liberty to put this order to execution in accordance with law.

The instant case is thus disposed of.

Let a copy of this order be given/handed over to the parties to this case free of cost.