By Smt. PREETHI SIVARAMAN.C, MEMBER

1. The complaint   in short is as follows:-

               Complainant  is  a  66 year old lady  and  she is the  wife of Mr. Changu.Mr.Changu had an account at Punjab National bank, Vengara branch, the second opposite party. One of the staff of  opposite party  bank insisted  complainant  and her husband to take ‘’Care Health Insurance’’  and  believing his words they had taken a health insurance policy for a sum insured of Rs.3,00,000/- to each insured subject and paid Rs.14,282/- as premium. Opposite party No.1 issued  a group  health insurance policy bearing No 17499225 and policy No.30248125 in the name of  Mr.Changu  with effect from 23/02/2021  till  22/02/2022. 

2.     Complainant is healthy and she had no age related health issues.  On 25/10/2021 she became Covid positive and on 29/10/2021 she had admitted at MIMS Hospital, Kottakkal. She had undergone treatment at MIMS Hospital nearly 6 days. From the hospital   they requested the opposite party No.1 for cashless claim.But opposite party No.1 rejected the claim of complainant. Thereafter complainant filed a complaint before opposite party No.2 bank,  but they washed their hands and  escaping from the  liability by putting  everything at  opposite party No.1’s shoulder. 

3.    Complainant spent an amount of nearly Rs. 44,879/- for her treatment, but she did not get the insurance amount from opposite party No.1 which she deserves to be get.  It is a clear deficiency in service and unfair trade practice from the side of opposite parties. By believing the words of the opposite parties, complainant’s husband   joined the insurance policy for cash less treatment. Hence she is entitled to get the insurance amount as offered by opposite parties. Complainant suffered mentally and financially due to the rejection of cashless claim by opposite party No.1.It  is a clear deficiency in service and  unfair  trade  practice  from the side of opposite parties. Hence this complaint.

4.    The prayer of the complainant is that, she is entitled to get a full refund of Rs. 44,879/- the amount spent for the treatment of complainant, Rs.1,00,000/-as compensation on account of deficiency in service  and unfair trade practice on the part of opposite parties and thereby caused mental agony, physical hardships and sufferings to the complainant and cost of the proceedings. 

5.          On admission of  the complaint  notice was issued to the opposite parties and notice served on them and opposite party No.1  appeared before the Commission through their counsel and filed version. Opposite party No.2 did not appear before the Commission and not filed version and affidavit. Hence opposite party No.2 set exparte.

6.     In their version, opposite party No.1 denied all the allegations levelled by complainant against them except those which are admitted there under. Opposite party No.1 admitted that they issued an insurance policy to the complainant. They again stated that insurance policy is a contract and the rights and liabilities of the parties are governed by the terms and conditions of the contract and the wordings for all contracts of insurance are approved by IRDAI, the statutory body for insurance matters. They admitted that they issued a group health insurance policy bearing No.17499225 to Punjab National bank thereby covering its customers, that means Mr.Changu and his wife Mrs. Nalini with effect from 23/02/2021 till 22/02/2022 for a sum insured of Rs.3,00,000/- to each insured subject to policy terms and conditions.

7.       They again stated that they received a request for cashless claim   from  the hospital  in which complainant was admitted and  on going through the documents submitted by the hospital, it appeared that  complainant  had been inflicted with a mild form of Covid -19 which in the opinion of the  medical experts  of  them  could be managed with home quarantine. As per the ICMR and Ministry of Health and Family Welfare guidelines for Covid cases “ mild symptom with  Covid cases  can be managed with  isolation/home quarantine’’.  In this case all the vitals such as  CRP,   D Dimer, PCV were within normal limits only,  hence  she could have been  easily managed on OPD basis.

8.     Hence cashless hospitalisation request was not approved and this was intimated to the treating hospital immediately. Cashless claim is an additional facility that is offered by the insurer and it is not something guaranteed in the policies. It is granted at the discretions of the insurer on a case by case basis after perusing the documents available at the time of receipt of the request.  No extra premium is collected for this facility. The assurance in the policy is only of reimbursement of expenses if the claim is admissible according to the terms and conditions and exclusions of the insurance policy. Complainant has not submitted any claim for reimbursement of expenses. Denial of cashless request is not denial of claim in toto. 

9.    They also requested to the complainant to submit  some documents  like  1) Discharge summary 2) Medical and Laboratory reports 3) Bills, Receipts 4) NEFT/KYC of Proposer, so that  the opposite party can assess whether  the claim can be  paid as per the  terms and conditions of the  policy.   They again contended that the claim of insured was rejected as per the below clause: 5. Exclusions, 3. Permanent Exclusions A) 1. Any item or condition or treatment specified in list of non-medical item,

     2. Hospitalisation for evaluation/Diagnostic purposes.

10.       They again contended that on receiving the above mentioned documents, if the claim is payable according to the terms and conditions of the policy, they will make the payment to complainant directly or deposit it before the Commission.  The claim is not payable as per the terms and conditions of the policy, this fact will be submitted to the Commission with reasons.  There is no deficiency of service from their side. 

11.    In order to substantiate the case of the complainant, she filed an affidavit in lieu of Chief examination and the documents she produced were marked as Ext. A1 to A9.  Ext.A1 is the copy of insurance certificate of Mr.Changu. Ext.A2 is the copy of Discharge summary issued from Aster MIMS Hospital to complainant on 20/03/2023.  Ext.A3 is the copy of the patient bill issued from Aster MIMS Hospital dated 03/11/2021.  Ext. A4 is the copy of Covid -19 test report dated 25/10/2021. Ext. A5 is the copy of scanning report (HRCT-Thorax) given by Aster MIMS hospital to complainant dated 30/10/2021. Ext. A6 is the copy of Denial letter issued by  opposite party No.1 to  MIMS Hospital Changuvetty , Kottakkal dated 02/11/2021. Ext. A7 is the copy of complaint filed by complainant before opposite party No.1.  Ext. A8 is the copy of complaint filed by Mr.Prajeesh before Branch Manager, opposite party No.2 Bank on 02/11/2021. Ext. A9 is the copy of Certificate issued by Aster MIMS regarding the infection of Covid-19 to complainant.

12.    Thereafter opposite party No.1 also filed affidavit and documents marked on Ext.B1 to B3.  Ext.B1 is the copy of the policy No.17499225 with terms and conditions dated 25/02/2021.  Ext. B2 is the copy of Pre authorisation form.  Ext. B3 is the copy of Investigation report from hospital dated 29/10/2021 (2 pages).

13.   Heard complainant and opposite party No.1 and perused affidavit and documents.  The following points arise for consideration:-

1. Whether there is any deficiency of service and unfair trade practice on the part of opposite parties.
2. If so, reliefs and cost.

14. Point No.1 and 2:-

           Case of the complainant is that, complainant  did not get the benefits of Care Health Insurance of opposite party No.1  which was  taken  due to the  compulsion from opposite party No.2, the sum assured  is Rs. 3,00,000/- with a premium of Rs. 14,282/-. She became Covid positive on 29/10/2021 and she had undergone treatment at MIMS Hospital nearly 6 days. Complainant stated that, it is a clear deficiency in service and unfair trade practice from the side of opposite parties.  Complainant stated that she had spent for an amount of Rs. 44,879/- for her treatment. 

15.   Opposite party admitted the insurance policy issued by them to the complainant, but it appeared that complainant had been inflicted by the mild form of Covid-19 which in the opinion of medical expert of them, could be managed with home quarantine. They again stated that   cashless claim is an additional facility that is offered by the insurer and it is not something guaranteed in the policies.  No extra premium collected for this facility. 

16.       As  per  Ext.A1 document  it is clear that, there is  an insurance policy  in name of complainant  and  her husband from 00.00 hours 23/02/2021  to midnight  22/02/2022. As per Ext.A2 document the discharge summary, it is clear that complainant was admitted at Aster MIMS Hospital on 29/10/2021 and she was discharged on 03/11/2021.  From Ext. A3 document it is clear that complainant paid Rs.44,879/- as expenses for her treatment.  In Ext. A4 document  the Covid -19 test report  reveals that  on 25/10/2021  at 05.02 PM  complainant is  reported  as  Covid positive. As per Ext. A6 the denial letter, opposite party wrote a letter to MIMS Hospital that the cashless hospitalisation cannot be approved as per the terms and conditions of the policy   stated as ''Admission not justified''. 

17.     As per  Ext.A1 document it is clear that  complainant was undergone treatment at MIMS Hospital  due to Covid -19 positive  while the policy was in force.  From Ext. A2 document it is clear that complainant was admitted at MIMS Hospital on  29/10/2021 and  after 6 days she was discharged from the hospital. As per Ext.A4 document it is clear that  the date and time of  reporting of Covid -19 positive of complainant is 25/10/2021 at 05.02 PM.  Hence as per the terms and conditions of the insurance policy, complainant is entitled to get the insurance benefit for cashless treatment which the opposite party stands denied. In their version and affidavit, opposite party No.1 admitted the group health insurance policy No.17499225 to Punjab National Bank thereby covering its customers Mr.Changu and his wife Mrs. Nalini with effect from 23/02/2021 till 22/02/2022  for a sum insured of Rs. 3,00,000/-. But when they received the request for cashless claim,   they verified the document submitted by hospital and it appeared that complainant had been inflicted with a mild form of Covid -19 and that could be managed with home quarantine. They again stated that all the vitals such as CRP,D Dimer , PCV were within normal limit , hence  complainant could have been  easily managed on OPD basis. Hence the request of complainant was not approved.  From the above contentions of opposite party No.1, we are on the opinion that it is not the insurance company who decide the condition of complainant.  Complainant was admitted in the hospital nearly 6 days that means 144 hours.The contention of opposite party is that  the complainant does not require  hospitalisation for  the Covid-19  is ridiculous.  As per Ext.A4 document it is clear that complainant was Covid -19 positive on 25/10/2021  and she was admitted  in hospital  on 29/10/2021, after 4 days of reporting of Covid-19 positive.

18.    Another contention of opposite party No.1 is that the cashless claim is an additional facility that is offered by the insurer and it is not something guaranteed in the policy.  It is granted at the discretion of the insurer on a case by case basis after perusing the documents available at the time of receipt of the request.  They again stated that no extra premium is collected for this facility.  The assurance in the policy is only of reimbursement of expenses. Moreover they submitted that complainant has not submitted any claim for reimbursement of expenses. Denial of cashless request is not  denial of claim  in toto.  But opposite party No.1 has not pointed out where the said matters are mentioned in the policy. From the arguments of opposite party No.1 we are on the opinion that the poor complainant is not aware how to approach the opposite party No.1 for reimbursement of the amount and   about the steps to be taken to get refund of the amount. There is no document from the side of opposite party No.1 to prove that they informed about the reimbursement of the amount to complainant.

19.      At the time of hospitalisation   complainant informed the hospital about their

Health insurance policy, but opposite party rejected the cashless claim of complainant. It is sure that complainant must have   been worried at that time. She is a senior citizen and the Covid -19 difficulties also will affect her at that time.  Moreover the condition of the complainant will badly affect the complainant  and her family too.  In the version of Opposite party No.1 , they stated that  the denial of cashless request is not denial of claim in toto. But we are on the opinion that poor complainant is not aware about the procedure to be followed for reimbursement of the amount. Opposite party No.1 not approved the request for pre authorization of cashless claim of complainant due to ‘admission not justified’.  There is every document there to prove the claim of complainant. Hence that act of opposite party No.1 not justifiable. So it is a clear deficiency in service and unfair trade practice from the side of opposite party No.1.

20.     In their version and affidavit  opposite party No.1 stated that  they  requested the complainant to submit some documents  like discharge summary, medical and lab reports , bills and receipts , NEFT/KYC of Proposer etc  to assess  whether the claim can be paid as per the terms and conditions of the policy. If the claim is payable according to the terms and conditions, then opposite party will make the payment. That statements are clear unfair trade practice from the side of opposite party No.1. Complainant taken the policy on 23/02/2021   but opposite party did not mention any thing at anywhere in the policy that  they will not  give  the benefits of the policy  for issues  like Covid-19 pandemic. There is no case for opposite party No.1, that corona is exempted from their health policy. More over opposite party No.1 did not produce documents to prove that they requested the complainant to submit the above  said documents  earlier.

21.      In their affidavit, opposite party No.1 stated that  complainant has not submitted  any claim for reimbursement of expenses. They again stated that on 30/10/2021 they wrote to the complainant requesting for documents, but complainant never replied. But they did not submit the document before the Commission to prove their contention. Opposite party No.1 again stated about a letter marked as Ext. B4. But there is no document like Ext.B4 from the side of opposite party No.1. We are on the opinion that if they have that type of arguments, they can submit the above points before the Commission on the very first posting for the appearance of them on 10/06/2022.  They can take initiative for a settlement between complainant and opposite party No.1.  On that day, they appeared before the Commission and filed version. Hence we are on the opinion that opposite party No.1 is submitting some negligible points to escape from their liability.

22.    Opposite party No.2 set exparte.  After getting notice opposite party No.2  was not present  and not filed their  version  and affidavit.  Hence they are also liable to compensate the complainant. Complainant’s case   is that due to the impulsion from opposite party No.2, Complainant’shusband taken the policy.  On 02/11/2021 complainant’s son wrote a letter to opposite party No.2 to inform the situations of complainant and the rejection of cashless claim of complainant by opposite party No.1. But they did not take any step to resolve the grievance of complainant.  Complainant taken the group insurance policy of Punjab National Bank.  Opposite party No.1 also admits the same.  In Ext. A1, there clearly mentioned the name of Group Insurance Policy holder is Punjab National Bank, opposite party No.2. But they  did not try to contact opposite party No.1 and  did not take any initiative  to settle the claim of complainant .

23.     So there is absolutely no justification for repudiation of cashless claim of the complainant. The right to determine the medicine and hospitalisation is decided by the doctor not the insurance company.  The Insurance Company cannot dictate the mode of Covid treatment and hospitalisation.  She was undergone treatment due to Covid -19 while the policy was in force.  The case of the complainant stands proved through the documents and affidavit. The denial of Insurance to the right policy holders amounts unfair trade practice and deficiency in service. Hence complainant is entitled for the amount spent for treatment.  In addition to that the complainant entitle reasonable amount of compensation which complainant claimed as Rs. 50,000/-. The Commission finds the claim of the complainant is reasonable one.  Complainant also entitled the cost of the proceedings and we find  the same as Rs. 10,000/-. Hence the Commission finds that there is deficiency in service and unfair trade practice on the part of the opposite parties as alleged in the complaint. Hence we allow this complaint holding that opposite parties are deficient in service.

24.   We allow this complaint as follows:-

1. The opposite party No.1 is directed to refund Rs.44,879/-(Rupees Fourty four thousand  eight hundred and seventy nine only)to the complainant the amount she had spent for her  treatment.
2. The opposite party No.1 is  directed to pay compensation of Rs.50,000/-(Rupees Fifty thousand only) to the complainant on account of deficiency in service on the part of opposite party No.1 and thereby caused mental agony, physical hardships and sufferings to the complainant.
3. The opposite party No. 2 is directed to pay Rs. 10,000/-(Rupees Ten thousand only)  as cost of the proceedings.

          If the above said amount is not paid to the complainant within 30 days from the date of receipt of copy of this order, the opposite party No.1 and 2 are liable to pay the interest at the rate of 12% per annum on the said amount from the date of receipt of the copy of this order till realisation.

Dated this 30^thday of June , 2023.

MOHANDASAN K., PRESIDENT

PREETHI SIVARAMAN C., MEMBER

MOHAMED ISMAYIL C.V., MEMBER

APPENDIX

Witness examined on the side of the complainant : Nil

Documents marked on the side of the complainant : Ext.A1to A9

Ext.A1 : Copy of insurance certificate  of Mr.Changu.

Ext.A2 : Copy of Discharge summary issued  from Aster MIMS Hospital to

               complainant on 20/03/2023. 

Ext.A3 : Copy of the patient bill issued from Aster MIMS Hospital dated 03/11/2021.  Ext. A4 : Copy of Covid -19 test report dated 25/10/2021.

Ext. A5 : Copy of scanning report (HRCT-Thorax ) given by Aster MIMS hospital to

               complainant dated 30/10/2021.

Ext. A6 : Copy of Denial letter  issued by  opposite party No.1 to  MIMS Hospital

               Changuvetty ,Kottakkal dated 02/11/2021.

Ext. A7 : Copy of complaint filed by complainant before opposite party No.1. 

Ext. A8 : Copy of complaint filed by Mr.Prajeesh before Branch Manageropposite

                party No.2 Bank on 02/11/2021.

Ext. A9 : Copy of Certificate issued by Aster MIMS regarding the infection of Covid-19

                to complainant.

Witness examined on the side of the opposite party : Nil

Documents marked on the side of the opposite party : Ext. B1 to B 3

Ext.B1 : Copy of the policy No.17499225 with terms and conditions dated

               23/02/2021.

Ext. B2 : Copy of Pre authorisation form. 

Ext. B3 : Copy of Investigation report from hospital dated 29/10/2021 (2 pages).

MOHANDASAN K., PRESIDENT

PREETHI SIVARAMAN C., MEMBER

MOHAMED ISMAYIL C.V., MEMBER