By Smt. Beena. M, Member:
This is a complaint filed under section 35 of the Consumer Protection Act 2019.
2. Brief facts of the case is as follows:- The Complainant had taken Family Health Insurance Policy from the Opposite Party on 24.05.2022 for himself and his family members for the period from 24.05.2022 to 23.05.2023 and paid Rs. 29,574/- as premium. The Opposite Party had assured under the policy that if the Complainant or the Complainant’s family were hospitalised for more than 24 hours due to any illness, the Insurance Company would give the entire hospital expenses. Thereafter, the wife of the Complainant admitted in the Mananthavady Vincent’s Hospital due to Acute Febrile Illness on 29.11.2022 and she was discharged on 02.12.2022. Then the Complainant submitted claim application before the Opposite Party on 09.12.2022 along with required documents for the reimbursement of Rs. 6,834/-, which was the hospital expenses. But the Opposite Party was not ready to pay the amount to the Complainant till the date. The Original documents provided by the Complainant were not returned despite being asked to return. No reason was given to the Complainant for rejection of claim. Hence, this Complaint.
3. Upon notice, the Opposite Party appeared and filed version.
4. The version filed by the Opposite Party is as follows:- The Opposite Party issued a health insurance policy from 24-05-2022 till 23-05-2023 covering the Complainant, his spouse and his son for a sum insured up to Rs.5,00,000/- subject to policy terms and conditions. The said policy was ported from Star Health Insurance Company Limited wherein first date of enrolment was 30.03.2014. Reimbursement claim was filed for the hospitalisation of the Complainant’s wife at St Vincent Hospital from 29-11-2022 till 02-12-2022, where she was diagnosed with acute febrile illness. Upon receipt of the claim, an investigation was also triggered to check the veracity of the claim and the claim was repudiated on the ground of (1) Admission not justified as treatment could be take on OPD basis. (2) Admission not justified as the relevant clause as per terms and conditions is reproduced herein below:
4.1 Standard Exclusions
Permanent Exclusions: Any claim in respect of any insured person for, arising out of or directly or indirectly due to any of the following shall not be admissible unless expressly stated to the contrary elsewhere in the policy terms and conditions.
1. Investigation and Evaluation:
a) Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
b) Any diagnostic expenses which are not related or incidental to the current diagnosis and treatment are excluded.
5. The replying Opponent has relied on the following judgments:-
In the Export credit Guarantee Corp of India Ltd. Versus M/s. Garg Sons International pronounced by the Hon’ble Supreme Court of India that the “The insured cannot claim anything more than what is covered by the Insurance Policy. The terms of the contract have to be construed strictly without altering the nature of the contract as the same may affect the interests of the parties adversely”. The clauses of an insurance policy have to be read as they are consequently, the terms of the insurance policy that fix the responsibility of the Insurance Company.
In a very recent judgment pronounced by Hon’ble Supreme Court in SGS India Vs. Dolphin International Ltd, LL 2021 SC 544 it was observed that the onus of proof of deficiency in service is on the complainant in the complaints under the Consumer Protection Act 1986. It is the complainant who had approached the Commission, therefore, without any proof of deficiency, the opposite party cannot be held responsible for deficiency in service.
In this regard the bench referred to the decision in Ravneet Singh Bagga V. KLM Royal Dutch Airlines (2000) 1 SCC 66 in which it was observed thus: The deficiency in service cannot be alleged without attributing fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be performed by a person in pursuance of a contract or otherwise in relation to any service. The burden of proving deficiency in service is upon the person who alleges it. The complainant has on facts been found to have not established any wilful fault, imperfection, shortcoming or inadequacy in the service of the respondent.
The court also noted that in Indigo Airlines v. Kalpana Rani Debbarma (2020) 9 SCC 424, it was held that the initial onus to substantiate the factum of deficiency in service committed by the opposite party was primarily on the complaint.
6. Thus, in light of the above stated contentions and averments it is submitted that the claim of the Insured has been rightly repudiated by the Opposite Party Company as per the Policy Terms and Conditions and as such there is no deficiency in service on the part of the Opposite Party Company. The Opposite Party prayed to dismiss the complaint with cost.
7. The Complainant filed proof affidavit and examined as PW1 and the documents produced were marked as Ext. A1 and A2 series. The Opposite Party submitted that they have no oral evidence but they have produced 5 documents which were marked as Ext B1 to B5.
8. Points for consideration:-
1. Whether there is any deficiency in service on the part of the Opposite
Party?
2. Whether the Complainant is entitled to get any relief as prayed for?
9. For convenience and brevity Point No.1 and 2 are considered together:- We have heard the Complainant and Opposite Party and have also perused the entire records. There is no dispute regarding the issuance of policy by the Opposite Party. When we gone through all the documents produced by the Complainant, it seems that as per Ext. A2 series Discharge Summary, the Complainant’s wife was admitted in St. Vincent’s Hospital, Mananthavady on 29.11.2022 and discharged on 02.12.2022 for Acute Febrile Illness. Now coming to the ground of repudiation, the Opposite Party stated that the treatment during hospitalisation was not necessary as inpatient care but it could be taken at OPD basis. We are guided by the discharge Summary issued by the hospital with respect to Complainant’s wife which is suggestive of her suffering from Acute Febrile Illness with acute gastroenteritis, elevated CRP,ESR and clinical notes shows C/O decreased appetites X 2 days, loose stools, vomiting 2 days, fever, headache sore throat pain. This revealed that the said ailments for which several tests were got done during the period of hospitalisation. Here the Opposite Party failed to explain how the Acute Febrile Illness be treated in OPD basis and the Opposite Party neither placed on file any record nor any opinion of the expert doctor, who examined the reports of insured. Since the Opposite Party has failed to place on record any opinion of the expert nor has furnished affidavit of any such expert, who has examined and investigated the reports of the insured. Therefore, the plea the Opposite Party appears to be devoid of merits and is seen that the Opposite Party has illegally rejected the claim of the Complainant. Therefore, we are of the opinion that the treatment taken by the Complainant was proper which could not cure in OPD basis. As the treatment taken by the Complainant does not come under the OPD basis, the repudiation is not as per policy exclusion clause No.4.1. This is not applicable to the claim of the Complainant. The doctor is the best person who can take decision about the treatment. Therefore, on the above discussion we are on the view that the repudiation of the claim is illegal, which is wrongly repudiated by the Opposite Party. Therefore, the act of Opposite Party is deficiency in service and unfair trade practice. So, the Complainant is entitled to get the claim amount with compensation and cost.
In the result, the complaint is partly allowed, and the Opposite Party is directed to pay the claim amount of Rs.6,834/- (Rupees Six Thousand Eight Hundred and Thirty Four only) and to pay Rs.10,000/- (Rupees Ten Thousand only) towards compensation and cost of the proceedings.
The above order shall comply within 30 days from the receipt of this order, failing which the Complainant is entitled to get 9% interest for the above amount.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 5th day of August 2024.
Date of filing:12.04.2023.
PRESIDENT : Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:
PW1. Mammootty. K. P. Complainant.
Witness for the Opposite Party:
Nil.
Exhibits for the Complainant:
A1 series. Copy of Invoice.
A2 series. Copy of Claim Form.
Exhibits for the Opposite Party:
B1. Copy of Policy Certificate.
B2. Copy of Claim Form.
B3. Copy of Discharge Summary.
B4. Copy of Claim Denial Letter. dt:05.01.2023.
B5. Insurance Policy Terms and Conditions.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
