By Sri. A.S. Subhagan, Member:
This is a complaint preferred under section 35 of the Consumer Protection Act 2019.
2. Facts of the case:-
The Complainant had taken a Chola Swastha Parivar Policy launched by the second Opposite Party, from the first Opposite Party on 12.02.2016, after paying Rs.2,955/- towards premium. The Policy number is 28560019358900000. Thereafter the Complainant renewed the policy regularly and the policy is still in force. While so, during December 2019, the Complainant developed pain on her lower back. In the beginning, the Complainant didn’t take it seriously. Since the pain didn’t subside, the Complainant consulted an orthopaedic surgeon Dr.Suresh Kumar at Government District Hospital, Mananthavady on 19.12.2019. After taking the MRI of her hip, the Complainant consulted him again on 03.01.2020. The doctor told the Complainant that surgery was the only remedy and advised her to take treatment at Ganga Hospital, Coimbatore. Accordingly, the Complainant consulted Orthopaedic Surgeon Prof. S. Rajasekharan at Ganga Hospital, Coimbatore on 13.01.2019. The doctors prescribed medicines and asked the Complainant to come again in February, 2020. The doctor also told her to get prepared for a surgery, if required. Accordingly, the Complainant was admitted at Ganga Medical Centre & Hospitals, Coimbatore on 24.02.2020. Various tests were conducted and the Complainant’s illness was diagnosed as L4-L5-S1 instability and L5-S1 Spondylodiscitis with stenosis and bilateral radiculopathy. Surgery was suggested and the same was done on 26.02.2020. Cashless treatment was not provided to the Complainant. The Complainant was discharged on 02.03.2020 with advice to take rest, take oral medicine and come for review after 4 weeks. The Complainant spent a total amount of Rs.1,93,603/- for her treatment. Immediately after the discharge from the hospital, The Complainant submitted the claim form to the second Opposite Party for the reimbursement of the treatment expense of Rs.1,93,603/-. But, instead of reimbursing the amount, the second Opposite Party sent a letter dated 24.08.2020 repudiating the claim for reimbursement. The reason given for repudiation is that the Complainant did not submit the requested documents. The said allegation is wrong, without any basis and with ulterior motives. The Complainant had submitted all the available records pertaining to her illness and treatment. At the time of taking the policy, the Complainant was assured that cashless treatment would be provided in hospitals and the Complainant need not have to pay anything for treatment. The Complainant was not provided with cashless treatment. Though the Complainant was financially poor, she was constrained to take the expensive treatment only as she was made believe that the Opposite Party would honour its word and reimburse the treatment expense. Since the Opposite Party turned down the request for cashless treatment, the Complainant’s husband had to run from pillar to post to arrange the amount for paying the hospital bills. As per the terms of the policy, the Opposite Parties are legally bound to satisfy the Complainant’s claim. But the second Opposite Party has repudiated the genuine claim of the Complainant without any valid reason. The act and omission on the part of the Opposite Party in not settling the claim of the Complainant would amount to deficiency of service and unfair trade practice. Due to the deficiency of service on the part of the opposite parties the Complainant has suffered loss, hardship, agony, and damage, for which the Complainant claims Rs.50,000/- as compensation. The Opposite Party is legally liable to compensate the Complainant.
3. Hence this complaint with prayers:-
(1) To direct the Opposite Parties to pay Rs.1,93,604/- to the Complainant towards reimbursement of the amount paid by the Complainant as treatment expenses with interest
(2) To direct the Opposite Parties to pay Rs.50,000/- to the Complainant towards compensation
(3) To direct the Opposite Parties to grant Rs.10,000/- towards cost of this proceedings and
(4) To grant any other relief that this Commission deems fit to grant.
4. Notices were served upon the Opposite Parties for appearance. They appeared before the Commission and filed version.
5. Contents of version filed by the Opposite Parties:-
According to the Opposite Parties, there is absolutely no deficiency in service warranting the jurisdiction of this Commission. The claim of the Complainant was analysed and on perusal of the claim documents and verifying the medical records from the treated hospital, it was found that the Complainant had pre-existing diseases prior to the inception of policy which is not covered under the policy and hence the Opposite Parties issued several query letters for submission of medical records to show the history of previous ailments. In spite of several query letters the Complainant failed to submit the previous treatment records. Since she failed to submit the previous treatment records the claim was repudiated for non-submission of requested documents. In view of this non- disclosure of material information, the contract of insurance becomes void and no claim is payable under this policy. Hence the complaint is not maintainable and may be dismissed inlimine with cost of the Opposite Parties. This Opposite Party issued a Chola Swastha Parivar Policy to the Complainant for the period from 26.02.2021 to 25.02.2022 for a total floater sum insured of Rs.2,00,000/-subject to terms, conditions and exclusion clause of the policy. The Complainant submitted a claim form on 02.03.2020 for medical expenses undergone by the Complainant at Ganga Medical Centre and Hospital Private Limited, Coimbatore for the period from 24.02.2020 to 02.03.2020. The discharge summary issued by Ganga Hospital showed the previous history of present ailments as diagnosed therein. The claim was analysed and investigation team was deputed for verifying the hospital records. On perusal of hospital records, it was observed that the patient underwent treatment for back pain in Santhigiri Ayurveda and Siddha Hospital on 01.08.2016. Since the discharge summary showed previous history of ailments, the Opposite Party requested the Complainant to furnish details of onset, progress and documents of the ailment and treatment taken by the Complainant till date, for further processing of the claim. In spite of several reminder letters, the Complainant failed to submit the previous treatment records to rule out, the pre-existing decease. Since the Complainant did not respond to the said letters, the Opposite Party repudiated the claim for non-submission of requested documents. There is no merit and bonafide in the complaint and no cause of action for the complaint has arisen. The Complainant has not suffered any mental agony or pain due to the act of the Opposite Parties and hence they are not entitled to get any amount on that count. The cause of action stated is not correct. The Complainant is not entitled to get any of the reliefs as prayed for in the complaint. The Complainant is not entitled to get any amount of compensation and interest from the Opposite Party. The Complainant is not entitled to get cost, instead the Complainant is liable to pay cost of the Opposite Party. According to the Opposite Parties, there is no deficiency in service. Hence, it is prayed to dismiss the complaint with compensatory cost of the Opposite Parties.
6. Affidavit was filed by the Complainant, Exts.A1 to A5 and A6 series were marked from her side and she was examined as PW1. Ext.B1 to B5 documents were marked from the side of the Opposite Parties. The Opposite Parties had no oral evidence.
7. Considering and perusing the complaint, version, affidavit of the Complainant, documents marked from both the sides and the arguments of the Counsels for the parties, Commission raised the following points for consideration.
1). Whether there has been any deficiency in service/unfair trade
practice from the part of the Opposite Parties…?
2). If so, Relief and Cost..?
8. Point No.1:- The Complainant had taken a Chola Swastha Parivar Policy (launched by the second Opposite Party) from the first Opposite Party on 12.02.2016. Thereafter, the Complainant had renewed the policy regularly and the policy is still in force. The case of the Complainant is that though she had submitted claim form to the Opposite Parties, after undergoing treatment and surgery in Ganga Hospital, Coimbatore, the Opposite Parties neither provided cashless treatment nor reimbursement of her claim of Rs.1,93,603/-. The Opposite Parties repudiated the genuine claim of the Complainant without any valid reasons which is deficiency in service /unfair trade practice from the side of the Opposite Parties and hence the Complainant has approached this Commission with prayers as stated in the complaint. The Opposite Parties admitted that the Complainant had a valid Chola Swastha Parivar Policy upto 25.02.2022 for a total floater sum insured for Rs.2,00,000/-. The contention of the Opposite Parties is that an analysis and perusal of the claim documents and verifying the medical records from the treated hospital, it was found that the Complainant had pre-existing diseases prior to the inception of the policy which is not covered under the policy and hence the Opposite Parties issued several query letters for submission of medical records to show the history of previous ailments. But, in spite of several query letters, the Complainant failed to submit the previous treatment records and therefore, the claim was repudiated for non-submission of requested documents. The Opposite Parties have also contended that the discharge summary issued by Ganga Hospital showed the previous history of present ailments as diagnosed therein and on perusal of hospital records, it was observed that the patient had underwent treatment for back pain in Santhigiri Ayurveda and Siddha Hospital on 01.08.2016 and hence the Opposite Parties submitted that there has been no deficiency in service/unfair trade practice from their side and hence prayed to dismiss the complaint with compensatory cost. On analysis of the facts of the case and the documents we observe the following:
1) The Complainant had a valid insurance policy upto 25.02.2022 which is admitted by the Opposite Parties.
2) Ext.A4 document, which is the Discharge Summary issued from Ganga Hospital reveals that the Complainant was admitted there on 24.02.2020 and after treatment discharged from there on 02.03.2020, which is well within the coverage period of the insurance policy.
3) Ext.B4 document reveals that the Complainant was admitted in Santhigiri Ayurveda and Siddha Hospital on 01.08.2016 and was discharged from there on 15.08.2016. She is seen treated there for low back ache, swelling present in both thighs, after a fall, one month back.
4) In oral examination of PW1, it is stated that ‘’Cu tcJbn Rm³ Hcp amkw ap³]v hoWp F¶pw F\n¡v ]pdwthZ\ Dv F¶pw, Fsâ cv XpSbnepw \ocpmbncp¶p F¶pw FgpXn ImWp¶p F¦n AXv im´nKncn Bip]{Xnbn \n¶pw thZ\ ImWns¨¦nte ¢bnw In«q F¶v ]dªXn\m tUmISsd sImv A{]Imcw FgpXn¨XmWv. 2016  Rm³ ¢bnw t^mw sImSp¯n«nÃ. im´nKncnbn F\n¡v kpJNnInÕbmWv \ÂInbXv. _t¯cnbn \n¶v h¶v t]mIm³ _p²nap«pffXn\memWv AhnsS InS¶Xv’’. Here, even though the contention of the Opposite Party that the Complainant was admitted and treated in Santhigiri Ayurveda and Siddha Hospital during the period from 01.08.2016 to 15.08.2016 for back pain due to a fall one month back, the contention of the Opposite Parties that the Complainant had pre-existing disease on the date of commencement of the coverage for the first time ie 12.02.2016 as per Ext.B1 document marked by the Opposite Parties cannot be accepted as the admission and treatment due to a fall before one month in Ganga Hospital is done after the date of commencement of the coverage for the first time of the policy. The fall and the treatment due to the fall after the commencement of the policy shall not be considered as treatment for pre-existing disease.
5) It is seen that the Complainant had taken the insurance policy with coverage with effect from 12.02.2016. But she was admitted in Ganga Hospital only on 24.02.2020 which is after the completion of 48 months from the date of commencement of the insurance policy and hence the plea of the Opposite Parties that the Complainant is not eligible for insurance claim on account of pre-existing disease is baseless, illegal and unjustifiable. This type of attitude of the insurance companies to deny genuine claims of the policy holders with crooked mind to grab the moneys of the policy holders for unlawful enrichment of money can no way be admitted and hence to be condemned. Moreover, this unjustifiable and unfair trade practice shall ultimately reduce the faith of the people in insurance companies resulting in the reduction in their business and profit earning capacity leading to liquidation/dissolution of insurance companies in future. Repudiation of the genuine claims of the policy holders without having sustainable and valid grounds amounts to deficiency in service/unfair trade practice to cheat the innocent and eligible consumers. Here, in this case there has been deficiency in service/unfair trade practice from the part of the Opposite Parties as they have repudiated the genuine claim of the Complainant without any reasonable grounds. Other contentions of the Opposite Parties are immaterial to the facts of the case and hence discarded. So, Point No.1 is proved against the Opposite Parties.
9. Point No.2:- As Point No.1 is undoubtedly proved against the Opposite Parties, they are liable to compensate the Complainant by paying the claim amount, which is not disputed by the Opposite Parties, Compensation and Cost.
In the result, the complaint is allowed and the Opposite Parties are ordered to
- To pay Rs.1,93,603/- (Rupees One Lakh Ninety Three Thousand Six Hundred and Three Only) being the valid insurance claim amount together with interest @ 8% per annum from the date of repudiation of the claim.
- To pay Rs.50,000/- (Rupees Fifty Thousand Only) as compensation and
- To pay Rs.10,000/- (Rupees Ten Thousand Only) as cost of this complaint.
The above amounts shall be paid jointly and severally by the Opposite Parties 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 30th day of March 2023.
Date of Filing:-16.11.2020
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
APPENDIX.
Witness for the Complainant:-
PW1. Kathreena. Housewife.
Witness for the Opposite Parties:-
Nil.
Exhibits for the Complainant:
A1. Copy of Claim Repudiation Letter.
A2. Copy of Prescription by Dr. T. P. Suresh Kumar. Dt:19.12.2019.
A3. Copy of Prescription from Ganga Hospital. Dt:13.01.2020.
A4. Copy of Discharge Summary from Ganga Hospital.
A5(a). Copy of Cash Bill. Dt:02.03.2020.
A5(b). Copy of Cash Bill. Dt:26.02.2020.
A5(c). Copy of Cash Bill. Dt:26.02.2020.
A6(a). Copy of Chola Swasth Parivar Insurance Policy for the period of
26.02.2019 to 25.02.2020.
A6(b). Copy of Chola Swasth Parivar Insurance Policy for the period of
26.02.2020 to 25.02.2021.
Exhibits for the Opposite Parties:-
B1. Copy of Chola Swasth Parivar Insurance Policy for the period of
26.02.2019 to 25.02.2020.
B2. Copy of Claim Repudiation Letter. Dt:24.08.2020.
B3. Copy of Health Claim Query Letter. Dt:19.05.2020.
B4. Discharge Summary from Santhigiri Hospital and Siddha Hospital.
B5. Copy of Proposal Form. Dt:10.02.2016.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR
CDRC, WAYANAD.
