By. Smt. Bindu. R, President:

            This is a complaint is filed under section 35 of the Consumer Protection Act 2019 by Arunkumar. K. C, Kalathuparambil House, Sasimala Post, Padichira, Wayanad against Benny and others alleging deficiency of service and unfair trade practice from the side of Opposite Parties.

            2.  The main allegations raised by the Complainant in the complaint is that the Opposite Party No.1 who is the agent and representative of Opposite Party No.4 joined Complainant in a Health Insurance Policy P/181315/01/2021/005959 on 17.12.2020 and the Complainant paid Rs.3,869/- towards the premium of the said policy through Opposite Party No.1.  The Opposite Party No.2 is the Branch Manager in Wayanad and Opposite Party No.3 is the Zonal Office of the said Company. The Complainant joined in the health insurance policy through the Opposite Party No.1 who is the agent of insurance company, after approaching the Complainant in several occasions and made him to believe that the policy is the best and suitable for his age, and the Complainant renewed his policy annually through the agent without fail. The policy herein is the 4th renewal. The opposite parties had given annual renewal policy and promised to render service for the said policy. The opposite parties had advertised in website and made the Complainant to believe that the said health insurance policy is the best among the available and that if any claim occurs; the same should be accepted then and there without delay and the Opposite Party No.1 has also made him to believe that the claims will be refund or reimbursed instantly. Complainant had joined in Policy after medical examination as directed by agent. The complaint suffered some illness like reduced sleep at night and increased day time somnolence and this affected his driving skill at day time and working nature for an year. He approached doctor at Vinayaka Hospital Sulthan Bathery for the first time, but illness could not be identified and then he consulted with doctors at Iqraa Hospital and MIMS Calicut and Complainant was referred to Amrita Institute of Medical Science and Research Centre, Kochi. He was admitted as an inpatient in Neurology Speciality on 12.03.2021 and discharged only on 15.03.2021 after diagnosis and initiated treatment. The Complainant had remitted an amount of Rs.30,000/- as bill for his all treatment expenses including consultation, room rent, medical check-up for above said admitted period. The Complainant approached the Opposite Party No.1 for the reimbursement of the medical expenses by way of reimbursement/cashless treatment for the health policy purchased, and then he approached the Opposite Party No.2 for the reimbursement of the claim and submitted the entire medical bills along with claim form. The Opposite Party No.2 forwarded his request to the Opposite Party No.3 for settling the claim, the Opposite Party No.3 repudiated the claim without stating any valid reasons and not even returned the medical bills, it was kept by the company themselves; At the time of receiving Policy amount the opposite parties ensured that the Complainant can claim for reimbursement/refund in case of any treatment or admission at the hospital. Here the Complainant had admitted at the hospital for 3 Nights and 4 days, the room rent expenses, consultation charges and other medical expenses was paid by the Complainant and his claim for the same was denied by the opposite parties without stating any sufficient reasons. And this Complainant firmly believes that this opposite parties someway evade from the legal necessity payment to the Complainant by stating such lame excuses.  Actually this Complainant is a good and reliable customer of the opposite parties without failing any of his annual payments in the case of the renewal of said policy, by believing the opposite parties the Complainant took his treatment in a reputed and well settled hospital like Amrita Hospital he firmly believed that his cashless treatment or medical reimbursement will suddenly made by the Opposite Parties then and there when the Complainant discharge from the hospital. But in this case he was totally cheated and he is having mental agony due to the said acts of the opposite parties. That was unexpected and the Complainant struggled so much for settling his bills and other expenses of the said hospitalisation. It is a clear violation of the policy conditions and it’s a shear misbehaviour to the Complainant and it's an unfair trade practice too.  The Opposite Party No.1 being the authorised agent, Opposite Party No.2 being the Authorized Branch Office/Manager of the said Insurance Company, the Opposite Party No.3 being the Zonal Office of the said Insurance Company and the Opposite Party No.4 being the Registered Head Office of the said Insurance Company are jointly and severally liable to refund or payment of insurance claim within a reasonable time and without causing much inconvenience to the Complainant. But they are failed to give proper service to the Complainant and it caused heavy inconvenience to the Complainant. The Complainant had spent a huge amount to purchase the said insurance and at the same time for his medical expenses, but the Opposite Parties failed to provide the assured specifications and it is unfair and unethical trade of  practice and it caused heavy damages and inconvenience to the Complainant and the opposite parties are liable for the same. There is deficiency of service on the part of opposite parties and because of that the Complainant sustained injury and hardships. Therefore the Complainant approached this Commission praying for issuing direction to the Opposite Party to reimburse the medical expenses incurred to him amounting to Rs.30,000/- along with other reliefs.

            3.  Upon notice from the Commission Opposite Party No.1 to 4 appeared and filed a joint version. 

            4.  The contentions taken by the Opposite Parties in their version is that the Complainant had taken Medi Classic Insurance Policy (Individual) from the Opposite Party No.2 on 16.11.2018 for a sum insured of Rs.2,00,000/- which has been renewed up to 16.12.2021 vide policy No.P/181315/01/2021/005959.  At the time of issuing the policy the Complainant were 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 policy schedule.  Moreover, it is clearly stated in the policy schedule that “THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS CLAUSES, WARRANTIES, EXCLUSIONS ETC.. ATTACHED”.  It is submitted that the Opposite Parties had received a request for cashless treatment from Amrita Institute of Medical Sciences, Kochi stating that the Complainant was admitted at the Hospital on 12.03.2021 and was provisionally diagnosed with Probable narcolepsy with Obstructive sleep apnea.  Based on the available medical records, it is seen that the treating doctor has not given any clarification/reasons for hospitalization/ Inpatient treatment. Moreover it was observed that the health condition and the nature of treatment given would have been necessitated an outpatient treatment only and no hospitalization was necessary.  From the available documents it is clear that the condition of the Complainant does not require hospitalization. Hence the opposite parties had denied the pre authorization request for cashless treatment and the same was informed to the Complainant and the hospital vide letter dated 08.03.2021.It is submitted that after discharged from the hospital, the Complainant had submitted completed claim form with Medical Certificate, treatment summary, Bills for Rs.22,869/- and lab reports. As per the medical records submitted by the Complainant, it is observed that during the hospitalization clinical examination and investigations were done and no active line of management was given to the Complainant. From the available documents submitted by the Complainant, it is observed that the admission is mainly for investigation and evaluation only and the nature of treatment given would have necessitated an outpatient treatment only. Since there is no positive existence of any illness requiring confinement in a hospital, the claim falls under Exclusion clause No.IV (4) A of the policy. As per Exclusion No.1V (4) A of the policy, the company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of: Charges incurred on diagnostic that are not consistent with the treatment for which the insured is admitted in the hospital/nursing home. Admission primarily for            diagnostic purpose with no positive existence of sickness/disease/ailment/injury and no further treatment is indicated. Hence the Opposite Party had repudiated the claim as per terms and conditions of the policy and informed the Complainant vide letter dated 06.05.2021.  The Complainant thereafter had submitted a representation to reconsider the claim and the Opposite Party considering the same as an appeal against the original decision, had re-opened the claim and had sought an expert opinion and the expert also confirms that the line of treatment is for investigation and evaluation only. Hence the re-open request was also rejected vide letter dated 05.07.2021. The Complainant had taken the policy after fully understanding the terms and conditions of the policy and it was specifically explained to the Complainant that the policy is subject to terms and conditions. The allegation of the Complainant that, he had joined the policy after medical examination is baseless, bereft of truth and are denied. It is submitted that as per the terms and conditions of the policy, the medical examination is conducted to the person who are above the age of 50 at the time of taking the policy. At the time of taking the policy, the Complainant’s age was 30 and hence there is no need for any medical examination to the Complainant. The policy to the Complainant was issued based on the declarations made in the proposal form.  The allegation of the Complainant that he had remitted an amount of Rs.30,000/- as bill for his treatment is not correct and are denied. It is submitted that as per the bills and records submitted by the Complainant before the opposite parties, the total bill amount is only Rs.22,869/-. The Complainant in order to mislead this Hon’ble Commission and to usurp illegal gains at the expense of opposite parties, had raised a false amount. The claim of the Complainant was repudiated by the opposite parties based on the medical records and as per the terms and conditions of the policy. From the treatment records it is clear that the Complainant had only undergone investigation and evaluation and there has been no active line of management during the hospitalisation.  The reason for repudiation was clearly stated in the rejection letter forwarded to the Complainant.  The Complainant had not suffered any mental agony because of any acts of the Opposite Parties.  There has been no violation of the policy condition and no unfair trade practice from the part of the Opposite Parties.

            5.  The Complainant was examined as PW1 and marked Ext.A1 to A3 from his side and OPW1 was examined and Ext.B1 to B5 are marked from the side of the Opposite Parties.

            6.  The following are the points to be analyzed in this case.

1. Whether there is any deficiency of service or unfair trade practice from the side of the Opposite Parties?
2. If so, compensation and cost to be awarded to the Complainant..?

7.  On verification of the complaint, evidences produced from the side of the Complainant, version and the evidences of the Opposite Parties, it is seen that the Complainant suffered some health illness like reduced sleep at night and increased day time somnolence and this affected his driving skill at day time and working nature for an year. He approached doctor at Vinayaka Hospital Sulthan Bathery for the first time, but illness could not be identified and then he consulted with doctors at Iqraa Hospital and MIMS Calicut, Complainant was referred to Amrita Institute of Medical Science and Research Centre, Kochi. He was admitted as an inpatient in Neurology Speciality on 12.03.2021 and discharged only on 15.03.2021 after diagnosis and initiated treatment. The Complainant had remitted an amount of Rs.30,000/- as bill for his all treatment expenses including consultation, room rent, medical check-up for above said admitted period. The Complainant approached the Opposite Party No.1 and 2 for the reimbursement of the medical expenses and submitted the entire medical bills along with claim form. The Opposite Party No.2 forwarded his request to the Opposite Party No.3 for settling the claim, the Opposite Party No.3 repudiated the claim without stating any valid reason and not even returned the medical bills, it was kept by the company themselves. Here the Complainant was admitted in the hospital for 3 Nights and 4 days, the room rent expenses, consultation charges and other medical expenses were paid by the Complainant and his claim for the same was denied by the opposite parties without stating any sufficient reasons by stating such  lame excuses and the total expenses incurred by him for the treatment including admission in the hospital is Rs.30,000/-.  When the claim was preferred before the Opposite Party the Opposite Party repudiated the claim stating that admission in the hospital was not necessary for diagnosis and admission for diagnosis is exempted from the provision of the claim.  This has been emphasized by the OPW1 in the box “Amrita Hospital  sâ records R§Ä verify sNbvXXn Cu patient \v admission sNbvXXv investigation Dw evaluation th­n am{XamWv admit sNbvXXv F¶ GIImcW¯memWv claim reject sNbvXXv”.  He further deposed that “  A§ns\ reopen sNbvXtijw ho­pw repudiate sNbvXXv Chennai epff ]pd¯p\n¶pff specialist IfpsS opinion A\pkcn¨mWv specialist s\ ImWn¨v AhcpsS report {]ImcamWv ho­pw claim repudiate sNbvXXv F¶v version tem chief affidvavit tem ]dbmXncn¡m³ ImcWanÃ.  Expert opinion FSp¯p F¶p ]dªn«p­v   report lmPcm¡nbn«nÃ.  Report tImSXnbn lmPcm¡nbm AhcpsS Is­¯Â F´msW¶v a\Ênem¡m³ km[n¡pw”.

8.  From the above it can be seen that the claim was rejected by the Opposite Party Company only because of the reason stated above.  The Opposite Party had neither produced the report of the specialist stated to be obtained as stated by OPW1 in the box.  The report of the specialist is a very valuable document as far as the circumstances of the complaint is concerned.  Further it is also not known as to what are the offers the agent of the Opposite Party Company has given to the insurer at the time of issuing the insurance policy.  This also has been upheld by OPW1 in the box.  Above all these, it is not the Complainant who entered into admission in the hospital all by himself but the doctor who examined him had admitted him in the hospital.  Therefore it is very clear that admission was essential for the patient (Complainant) or otherwise he ought not have been admitted by the Doctor.  Hence the argument of the Opposite Parties that hospitalization/inpatient treatment was not necessary as is observed from the health condition and the nature of treatment which would have necessitated only an outpatient treatment for the patient cannot be accepted.  It is also stated by the Opposite Parties that the pre-authorization request for cashless treatment was denied by them due to the above reason.

9.  The fact regarding the necessity of hospitalization for a patient and treatment as Inpatient is at the discretion and decision of the treating Doctor which the Insurance Company cannot decide.  In this case the Complainant was admitted by the Doctor which itself reveals that an inpatient treatment was required for him.  The Opposite Party had not produced any contra evidences except merely stating that they have taken an Expert opinion the report of which also has not been produced by them.

10.  In these circumstances Point No.1 is proved by the Complainant in his favour and the following orders are passed

1. The Opposite Parties are directed to reimburse an amount of Rs.30,000/- (Rupees Thirty Thousand Only) with 12% interest from 15.03.2021 till the date of payment to the Complainant
2. The Opposite Parties are also liable to pay an amount of Rs.10,000/- (Rupees Ten Thousand Only) towards compensation to the Complainant.
3. The Opposite Parties are also directed to pay an amount of Rs.5,000/- (Rupees Five Thousand Only) towards cost of the proceedings.

Needless to say that if the above Order is not complied by the Opposite Parties within 30 days from the date of receipt of a copy of this Order, the Opposite Parties are liable to pay interest @ 8% for the amount from the date of Order till date of realization except for the amount awarded as costs.

Consumer case is partly allowed.

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 February 2024.

Date of Filing:-27.10.2021.

PRESIDENT   :Sd/-

MEMBER       : Sd/-

MEMBER       : Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              Arunkumar. K. C.                                       Loading.

Witness for the Opposite Parties:-

OPW1.          Balu. M.                                                        Assistant Manager, Legal.

Exhibits for the Complainant:-

A1.                  Copy of Medi-classic Insurance Police (individual) for the period of

17.02.2020  to 16.12.2021.

A2.                  Copy of Discharge Summary.

A3.                  Copy of Repudiation Letter.                                Dt:05.07.2021.

Exhibits for the Opposite Parties:-

B1.                  Copy of Discharge Summary.

B2.                  Copy of Letter.                                                        Dt:17.12.2020       

B3.                  Copy of Progress Notes Draft Copy.

B4.                  Copy of Repudiation Letter.                                Dt:06.05.2021.

B5.                  Copy of Letter.                                                        Dt:05.07.2021.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

/True Copy/

Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-