By Sri. A.S. Subhagan, Member:-
This is a complaint preferred under Section 35 of the Consumer Protection Act 2019.
2. Facts of the Complaint:- The Complainant was insured under a Group Health Insurance Policy mooted by the Opposite Party and was issued a Health Wellness Card vide Customer ID. No.182347233 vide Policy No.04-21-1000-8433-00010462 and the Policy was commenced on 02.05.2020 in which the Complainant and his family members were joined. On 21.12.2020, the Complainant was admitted in P.V.S Hospital, Kozhikode and a surgery was done there and discharged on 24.12.2020. The hospitalization was duly informed to the Opposite Party and all medical records with bills were forwarded as required by the Opposite Party. But the Opposite Party repudiated the claim stating false and frivolous reasons under the pretext of General Denial Clauses. The averment of the Opposite Party that the Complainant is known to be suffering from diabetes, hypertension and dylipidemia for the last two years and these are pre-existing diseases etc are mere surmises created for denial of the lawful claim of the Complainant. At the time of inception of the policy, the Complainant was not suffering from diabetes etc. The amount spent by the Complainant for surgery is Rs.84,684/- and the Opposite Party is liable to indemnify the Complainant by paying the claim. The Complainant has not concealed any information from the Opposite Party. The denial of insurance claim is against the accepted principles of customer relation and the wanton act of repudiation of claim is nothing but deficiency in service of the Opposite Party. So the Opposite Party is liable to pay the amount spent by the Complainant for her treatment. Hence this complaint praying the following orders.
- To pass an order directing the Opposite Party to pay a sum of Rs.84,648/- to the Complainant with interest @ 12% per annum towards the cost of the hospital treatment.
- To pass an order directing the Opposite Party to pay a sum of Rs.25,000/- towards compensation to the Complainant.
- To pass an order directing the Opposite Party to pay cost of this complaint and
- To pass an order for such other or further reliefs, as the Complainant shall pray for and which the Commission deems fit to pass.
3. Though notice was served on the Opposite Party for appearance before the Commission, he was called absent and hence he was set ex-parte.
4. Chief affidavit was filed by the Complainant. Ext.A1 and A2 were marked from his side and he was examined as PW1.
5. The case of the Complainant is that being a member of the Group Health Insurance Policy with the Opposite Party, though he had submitted an insurance claim application together with hospital bills and other required documents regarding his treatment and surgery in P.V.S Hospital, Kozhikode, the Opposite Party repudiated his claim on flimsy grounds stating that the Complainant had not disclosed pre-existing disease such as diabetes, hypertension and dylipidemia for the last two years. According to the Complainant he had no diabetes etc at the time of inception of the Policy and added that he had not concealed any information from the Opposite Party and had disclosed true and complete information. The Complainant contents that the repudiation of claim was not made in goodfaith on valid and justifiable grounds and was without any reason or in-depth verification and objective transparent enquiry was on flimsy, malafide and legally untenable grounds and therefore, the Opposite Party is liable to pay the hospital bill amount of his claim of Rs.84,684/- and cost of the Complaint. On verification of the documents marked, it is seen that the Complainant was issued a Health & Wellness Card (Ext.A2) which reveals that he had a Group Health Insurance Policy with the Opposite Party. Ext.A1 reveals that the claim of the Complainant was repudiated by the Opposite Party. The Opposite Party had the Opportunity to contest the case but they did not do so. Hence we have no other option than to believe the case of the Complainant. The repudiation of the insurance claim of the Complainant on flimsy grounds without evidences is unfair trade practice/deficiency in service on the part of the Opposite Party. Here, there has been unfair trade practice/deficiency in service on the part of the Opposite Party.
6. Therefore the Opposite Party is liable to re-imburse the hospital bill amount of the claim, compensation and cost of the Complaint to the Complainant.
In the result, the Complaint is allowed and the Opposite party is ordered :-
- To pay the insurance claim amount of Rs.84,648/- (Rupees Eighty Four
thousand Six hundred and Forty Eight only) together with interest @ 8% per annum from the date of repudiation of the claim.
- To pay a compensation of Rs.25,000/- (Rupees Twenty Five thousand only and.
- To pay Rs.5,000/- being 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 29th day of September 2022.
Date of filing:16.07.2022.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the complainant:
PW1. Ayisha. M Complainant.
Witness for the Opposite Party:
Nil.
Exhibits for the complainant:
A1. Copy of Repudiation Letter. dt:13.03.2021.
A2. Copy of Health & Wellness Card.
Exhibits for the Opposite Party:
Nil.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR,
CDRC, WAYANAD.
