DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 27th day of November, 2023
Present : Sri. Vinay Menon V., President
: Smt. Vidya A., Member
: Sri. Krishnankutty N.K., Member
Date of Filing: 24/05/2022
CC/92/2022
Pradeepkumar C.P.,
S/o. Prabhakaran C.,
Sreekrishna, Snehanagar,
Nadakkavu, Angavalparambu,
Akathethara, Palakkad – 678 008. - Complainant
(By Adv. G. Abhilash)
Vs
- Cholamandalam MS GIC Ltd.,
Regd. Office: 2nd Floor, “DARE” House,
#2, N.S.C. Bose Road, Chennai – 600 001.
- The Managing Director,
Cholamandalam MS GIC Ltd.,
Regd. Office: 2nd Floor, “DARE” House,
#2, N.S.C. Bose Road, Chennai – 600 001. - Opposite parties
(OPs by Adv. P. Prasad)
O R D E R
By Sri. Vinay Menon V., President
1. Pleadings undisputed by both the parties are that the complainant is a beneficiary of a Covid care health insurance policy floated by the OPs. During the subsistence of a valid policy the complainant suffered Covid-19 attack and was hospitalised for 10 days. Even though the complainant was eligible to receive the entire amounts claimed, the opposite parties failed to allow the claim of the complainant. O.P.s held that the claim was repudiated as the condition of the complainant did not mandate admission in the hospital and required only outpatient treatment. It is on this ground that the claim was repudiated. This complaint results out of the repudiation of claim.
2. Based on the pleadings and counter pleadings, the following issues were framed:
1. Whether the OPs are justified in repudiating the claim of the complainant?
2. Whether the repudiation of the claim was as per policy conditions?
3. Whether there is any deficiency in service on the part of OPs in repudiating the claim?
4. Whether the complainant is entitled to the reliefs sought for ?
5. Any other Reliefs?
3. (i) Complainant filed proof affidavit and marked Exts. A1 to A10.
Marking of Ext.A8 was objected to on the ground that it is totally disconnected with the subject matter of the dispute. Ext. A8 is a rent deed to prove that the complainant has taken a premise on rent to carry out his business. Since occupation of the room is not a part of the dispute, Ext. A8 is not relied on.
(ii) OPs filed proof affidavit and marked Ext.B1 to B5.
Ext. B2 being incomprehensible, we refuse to rely on the said document.
Issue Nos. 1 & 2
4. Admittedly the complainant herein was hospitalized for a period of 10 days from 20/1/2021 to 30/1/2021 and per complainant the stay was covered under the policy.
Opposite parties have strongly repudiated this claim and has stated that the medical condition suffered by the complainant did not require hospitalization.
5. Ext.B1 is the policy schedule alongwith the policy terms and conditions. The cover provided by this policy is stated under the heading ‘Coverage’. Said clause is reproduced here under :
“4. COVERAGE
The cover listed below is in-built Policy benefit and shall be available to all Insured Persons in accordance with the procedures set out in this policy.
4.1 COVID Cover
Lumpsum benefit equal to 100% of the Sum Insured shall be payable on positive diagnosis of COVID, requiring hospitalization for a minimum continuous period of 72 hours. The positive diagnosis of COVID shall be from a government authorized diagnostic centre.
Note
- Payment will be made only on hospitalization for a minimum continuous period of 72 hours following positive diagnosis for COVID.
- This is one time benefit applicable for the entire tenure of the Policy and shall terminate upon payment of this benefit.”
In short, what is covered under this policy is the entire expenses incurred by the beneficiary who was hospitalized for a minimum continuous period of 72 hours, ie. 3 days.
6. Claim of the complainant was repudiated by the OPs based on Ext.B4 letter of repudiation. The relevant portion of Ext.B4 relating to repudiation of the claim is reproduced hereunder:
“Dear Sir/Madam,
We have received your request for reimbursement of claim for the above hospitalization. We have verified the same with respect to the coverage terms and conditions under the policy.
On scrutiny of the claim submitted, we observe that the claim is not admissible for the following reasons:
On perusal of the claim documents, it is observed that the treatment given during the hospitalization period doesn’t warrant in-patient admission; only oral medication were administered and Insured medical conditions was within normal limits and not requiring hospitalization as per Ministry of Health Guidelines.”
7. Law requires that the complainant has to prove his case. Burden of proof would be cast on the complainant to prove that his hospitalization was necessary by adducing cogent evidence. Herein, the complainant has failed to do so and in the normal course this complaint ought to have been dismissed.
But we are not resorting to such step in view of an anomaly that we observed on the part of the opposite parties.
8. Ext.B4 is a document that was issued by the OPs to the complainant stating the cause for repudiation of the claim. In Ext.B4 they state unequivocally that the medical conditions suffered by the insured were within normal limits, not requiring hospitalization as per Ministry of Health Guidelines. Incidentally these guidelines are produced and marked as Ext.B5. We do not doubt the wisdom of the contents of the guidelines. But we have our doubts regarding the procedure adopted by the opposite parties in arriving at a conclusion that the medical condition suffered by the complainant did not warrant hospitalization.
9. It goes without saying that the complainant was admitted under the discretion of the treating doctor. Whatever be his reasons, the said doctor found that the complainant’s condition warranted hospitalization and treatment as IP. We do not find any evidence which shows that the OPs had enquired or consulted with the treating doctor as regards the conditions of the complainant that warranted hospitalization. It seems that the claims section of the O.P.s sat in unilateral judgment over the wisdom of the treating doctor.
10. Such a conduct on the part of OPs in repudiating the claim of the complainant without seeking an explanation of the treating doctor is abhorrent and in bad taste and is nothing short of unfair trade practice.
11. We therefore conclude that the OPs are not justified in repudiating the claim of the complainant and that the repudiation of the claim was as not as per policy conditions.
Issue No. 3
12. Resultantly we find that there is gross deficiency in service and unfair trade practice on the part of the OPs.
Issue No. 4
13. Taking into consideration the conduct of the O.P.s, it would not be unfair to arrive at a presumption that the O.P.s had cheated large number of Insured Persons by resorting to such illegal and unfair repudiations. The complainant is entitled to even larger compensation than what he has claimed. But since he has restricted his claim to Rs. 20,000/- as compensation and Rs. 10,000/- as cost, we hold that the complainant is entitled to the reliefs sought for. But we hold that the complainant is not entitled to 18% interest. We restrict the interest rate to 10%.
Issue No. 5
14. Since the complainant has not produced any documents to prove the amount he has claimed, we are unable to quantify the amounts expended by him. Ext. B2 claim form being incomprehensible we are unable to arrive at a figure. But we hold that the complainant is entitled to the amounts mentioned in the claim form.
15. 1) The complainant is entitled to the entire benefit payable under the Ext.B4 policy schedule.
2) The complainant is entitled to an interest @10% from the date of submission of claim before the opposite parties till date of payment.
3) The complainant is entitled to a compensation of Rs.20,000/- as claimed.
4) The complainant is entitled to Rs.10,000/- as charges for legal expenses.
5) Opposite parties are directed to comply with directives 1 to 4 within a period of 45 days failing which the complainant will become entitled to a further solatium of Rs.500/- per month or part thereof from the date of this order till the date of final compliance of the above directives.
Pronounced in open court on this the 27th day of November, 2023
Sd/-
Vinay Menon V
President Sd/-
Smt. Vidya A.
Member
Sd/-
Krishnankutty N.K.
Member
APPENDIX
Exhibits marked on the side of the complainant :
Ext.A1 – Copy of policy schedule
Ext.A2 – Copy of Covid test report
Ext.A3 – Copy of Progress Note and Doctors’ Orders
Ext.A4 – Copy of Case Record
Ext.A5 – Copy of Nurses’ Records and Reports
Ext.A6 – Copy of Drug Administration Chart
Ext.A7 – Copy of Vital Signs Chart
Ext.A8 – Copy of rent agreement
Ext.A9 – Copy of lawyer’s notice dated 6/11/2021
Ext.A10 – Original acknowledgement card
Exhibits marked on the side of the opposite party:
Ext.B1 – Copy of policy schedule with terms and conditions
Ext.B2 – Copy of claim form
Ext.B3 – Copy of Microbiology report
Ext.B4 – Copy of claim repudiation letter
Ext.B5 – Copy of clinical management protocol of Covid 19
Court Exhibit: Nil
Third party documents: Nil
Witness examined on the side of the complainant: Nil
Witness examined on the side of the opposite party: Nil
Court Witness: Nil
NB : Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
