ORDER

SH. ARUN KUMAR ARYA (PRESIDENT)

1. The complainant has filed the present complaint alleging the deficiency in service on the part of OP.  The brief facts of the case are that the complainant is the mediclaim policy holder of OP-2 Insurance Company vide policy bearing no. 510000/48/2020/1791 w.e.f 14.11.2019 to 13.11.2020. It is alleged by the complainant that he received only four pages policy schedule and no other document pertaining to terms and condition of the policy was ever provided to him by OP-2. On 30.06.2020, the husband of the complainant got infected with Covid-19 infection during the pandemic situation, due to deteriorating health condition her husband was admitted to OP-1 hospital in ICU and finally despite the best efforts he could not survive and left to the heavenly aboard on 15.07.2020 vide death summary dated 16.07.2020.

It is alleged by the complainant that during the admission, she incurred a huge amount of medical expenses to the tune of Rs.10,30,168.91/-on the treatment of her husband. The complainant lodged the reimbursement claim with the OP. The OP Ins. Co. paid a sum of Rs.2,05,000/- to the complainant out of the total bill of Rs.10,30,168.91/-. It is alleged by the complainant that on various occasion she approached OP-2 and requested its official to release the balance claim, however under one pretext or the other they denied the claim. The complainant also sent a letter dated 28.12.2020 to OP-2, thereby calling it to reimburse the balance claim in question. Despite serving of the demand letter OP-2 did nothing, This compelled the complainant to knock the door of this commission for redressal of her grievance.

2. Notice of the complaint was sent to all the OPs.  OP-1 filed its written statement wherein it denied any deficiency in service on its part. It is further stated that the complainant has been charged for the treatment as per the standard services rendered by OP-1 hospital. It is further stated that in the entire complaint all the allegations raised in the complaint pertains to the non-payment of entire bill amount by OP-2, hence the present complaint is not maintainable against OP-1, as the non-payment of the entire bill by OP-2 is beyond the power and scope of OP-1. It is further stated that the present complaint be dismissed qua OP-1.

OP-2 filed its WS denying the deficiency in service on its part. It is further stated that the claim of the complainant has been rightly considered/processed/approved as assessed by TPA as per Delhi Government Package Rate, hence no case of deficiency can be made out qua OP-2 and the present complaint be dismissed with cost being a frivolous one.

3. All the parties have filed their respective pleadings. We have heard the argument advance at the bar and have perused the record.
4. The sole question for our consideration in the present complaint case is that whether the complainant is entitled for the entire medical expenses incurred by her against the treatment taken at OP-1 hospital.
5. It is argued on behalf of complainant that the OP-2 Ins. Co. had arbitraily deducted a sum of Rs.8,25,169/- from her total claim of Rs.10,30,169.91/- under the pretext that the OP Ins. Co. is liable to reimburse to the complainant the medical expenses on the treatment of Covid-19 as per the Delhi Government Package Rate, whereas the policy in question is having the enough sum insured i.e Rs.10,00,000/- and no such terms and conditions were incorporated in the policy in question nor were ever supplied by the OP company to the complainant, which specify that the claim of the complainant be reimbursed by OP Ins. Co. according to the Delhi Government Package Rate. Moreover, in the pandemic situation having no other option the complainant was compelled to admit her husband in OP-1 hospital to save his life, as there was no hospital beds available for his treatment. It is argued that the relief claim be granted.
6. On the contrary, OP-2 stuck up on the defense taken by him and justify the repudiation.
7. Some facts are not denied by the parties such as the policy in question treatment undergone by the patient. The OP-2 Ins. Co. partly allowed the claim of the complainant and deducted the balance amount by taking the shelter of Delhi Government Package Rate.
8. Admittedly, the power to lay down the guidelines are rest with the Government and a citizen is a mere spectator, to what state authority do and decide. If the hospital has charged over and above the package rate, the insurance is under obligation to pay such a charges to the insured as he had collected the premium from the insured and assured him to reimburse in case of any medical emergencies arose.
9. In the present complaint case, due to the pandemic situation the husband of the complainant suffered from Covid-19, he battled with the deadly Covid-19 and during his struggle he lost his life. The complainant who is the wife put all her efforts to save the life of her husband by admitting him to the hospital of OP-1 who charges huge medical expenses for the treatment of her husband. Having no other option the complainant was compelled to admit her husband in OP-1 hospital to save his life and as there was no hospital beds available for his treatment. The complainant was duly insured with the OP and OP is under legal obligation to honor the claim of the complainant to the extent of sum insured which it fails to do. On the issue of treatment of Covid-19 and the Delhi Government Package Rate we are guided by the recent judgment of Hon’ble Delhi High Court dated 22.11.2022, titled as Dinesh Kumar Vs Govt. of NCT of Delhi & Ors. In W.P (c) 15853/2022 in which it was held as under:

“The petitioner who had spend his hard earned savings, while undergoing the treatment to save his life, cannot be simply told that since respondent no. 5 has failed to abide by the circular dated 20.06.2020 issued by GNCTD, he should seek refund from the said hospital which saved his life. This court does not deem it appropriate or necessary to delve into the validity of the circular dated 20.06.2020, in the present petition where an officer of Delhi Higher Judicial Services is seeking simpliciter reimbursement of the amount for the bonafied expenses incurred by him for treatment at the respondent no. 5 hospital for Covid-19, when the city was engulfed with the second wave of the pandemic”.

In view of the above discussion as well as the judgment cited above we are of the considered view that the OP-2 Ins. Co. cannot escape from his liability by taking the shelter of Delhi Government Package Rateparticularly when the terms and condition of the policy in question does not contain any terms regarding the reimbursement of the claim to the extent of Delhi Government Package Rate. Hence, in our view the repudiation is unjustified and we hold OP-2 guilty of deficiency in service and direct it as under:

1. Pay to the complainant a balance sum insured alongwith interest @ 6% p.a from the date of filing of complaint i.e 17.02.2021 till realization.

2. Pay to the complainant a sum of Rs.20,000/- on account of pain and mental agony which will also include the cost of litigation.

OP-2 is directed to comply the order within 30 days from the date of receipt of this order failing which OP-2 is liable to pay to the complainant interest @9% per annum from the date of non-compliancetill realization.

Copy of the order be givento the parties free of cost. The orders be uploaded on www.confonet.nic.in.File be consigned to Record Room.

Announced in open Forum on   _____________.

(NIPUR CHANDNA)                                                           (ARUN KUMAR ARYA)

         MEMBER                                                                                  PRESIDENT