By Sri. Mohamed Ismayil C.V., Member.
The averments in the complaint are in brief:-
1. The complainant is an account holder in the bank of the third opposite party. The second opposite party is the staff of the third opposite party. It is averred that the third opposite party introduced a health insurance policy and adviced to subscribe the same. On the basis of instigation made by the third opposite party the complainant had subscribed policy of the first opposite party, the insurer. The name of the policy was “Arogya Sanjeevani”, Sum Insured is Rs.5,00,000/- and coverage of the policy was during the period between 14/11/2020 and 13/11/2021. The wife of the complainant was also a beneficiary of the policy coverage. Later the complainant had renewed the policy which was valid between 06/12/2021 and 05/12/2022. Thereafter, the complainant was affected with physical discomfort and fever hence he was admitted in MIMS hospital wandoor on 04/09/2022. So the complainant had contacted the second and third opposite parities for availing benefits of insurance coverage. The complainant had executed required documents to the hospital authorities for availing expenses of treatment from the first opposite party. On 07/09/2022, the complainant was discharged from the hospital. The hospital authority had issued a bill for Rs. 15,000/- as cost of treatment and in turn they had collected a cheque of Rs. 15,000/- drawn in favour of the hospital authority as security until disbursement of treatment expenses from the first opposite party. After a period of 20 days the hospital authority had contacted the complainant and demanded to make payment of Rs. 15,000/- as the first opposite party did not discharge the liability under policy coverage. On the basis of advice given by the second opposite party the complainant had remitted the treatment cost to the hospital. The complainant had contacted the opposite parties for several times but they were evaded on frivouls excuses. It is averred that finally on 25/11/2022 the second opposite party issued a claim rejection letter through wattsup .It is pleaded that the opposite parties are liable to reimburse expenses incurred for his treatment. Hence the act of rejection of claim is amounted to deficiency in service. The contention of the first opposite party that patient had admitted primarily for diagnostic and evaluation purpose is incorrect and against the terms and conditions of policy. So the complainant prayed for directions to reimburse Rs.15,000/-as cost of treatment , to pay Rs. 1,00,000/- as compensation for the deficiency in service and Rs. 25,000/- as cost of litigation .
2. The first opposite party received notice and submitted written version. The second and third opposite parties had received notices on 22/05/2023, but they did not submit written version before this Commission. Hence they are treated as exparte.
3. The first opposite party admitted issuance of policy as pleaded in the complaint. According to the first opposite party they did not commit deficiency in service. The repudiation of claim application was on the basis of terms and conditions of policy. As per Clause 7.1 of policy there was no active line of treatment noted and the vitals of the insured were not alarming. It is contend that the patient was admitted primarily for diagnostic and evaluation purpose. It is further contended that as per Clause 9.5 of the terms and conditions of the policy each and every claim under the policy shall be subject to a co-payment of 5% applicable to claim amount admissible and payable .Hence the first opposite party is shall not be liable to make any payment under policy.
4. The complainant and the first opposite party filed proof affidavits in lieu of evidence. The documents of the complainant are marked as Ext. A1 to A4. Ext.A1 document is the discharge summary dated 07/09/2022 issued from NIMS hospital, wandoor which show treatment for lower respiratory tract inspection and type II DM by the complainant. Ext. A2 document is the copy of policy schedule issued in favour of the complainant and his wife by the first opposite party which covered between 06/12/2021 and 05/12/2022. Ext. A3 document is the copy of discharge bill dated 07/09/2022 for Rs. 15,000/- by the NIMS hospital, Wandoor.Ext.A4 document is the copy of repudiation letter dated 25/11/2022 issued by the first opposite party. After filing of proof affidavit, the complainant had filed an application to appoint power of attorney to conduct the case. The Commission allowed the application. The documents produced by the first opposite party are marked as Ext. B1 to B3. Ext. B 1 document is the copy of policy schedule along with its terms and conditions. Ext. B2 document is the copy of discharge summary dated 07/09/2022 issued from NIMS hospital, wandoor . Ext. B3 document is the copy of repudiation letter dated 25/11/2022 issued to the complainant.
4. Heard the complainant and the first opposite party in detail. The Commission examined documents and affidavits availed for scrutiny and considered following points to resolve the consumer dispute.
(i) Whether all the opposite parties have committed deficiency in service?
(ii) Relief and cost?
Point No.(i)
5. The grievance of the complainant is that the first opposite party had repudiated claim application and issued Ext. A4 document denying benefits under policy coverage. The complainant challenged legality of Ext. A4 document and argued that he is entitled for reimbursement of Rs.15,000/-as per Ext.A3 document. The complainant also produced discharge summary to prove the treatment undergone by him at NIMS hospital wandoor, and the same is marked as Ext. A1 document. It is argued by the complainant that the act of repudiation is untenable, arbitrary and against the terms and conditions of policy. It is further argued that he had repeatedly contacted the opposite parties for availing insurance benefit but the opposite parties were responded in a lukewarm manner and also evaded from their responsibility.
6. Conversely, the first opposite party argued that repudiation of claim was purely on the basis of terms and conditions of the policy, hence there was no deficiency in service on their part. It is argued that as per clause 7.1 there was no active line of treatment and vitals of insured were not alarming. The first opposite party has produced Ext. B1 document in support of contentions made in that regard. According to the first opposite party the complainant was admitted primarily for diagnostic and evaluation purpose. It is also argued that Ext. A1 document does not show any procedures were performed in the treatment.
7. In the analysis of evidence, it can be seen that the complainant had subscribed insurance policy from the first opposite party. It has also come out in evidence that as per Ext. A2 document the third opposite party is the intermediary and the second opposite party is the staff of the third opposite party, who dealt with transaction related to subscription of policy. The Commission find that the repudiation of insurance claim as per Ext.A4 document is without basis and ignoring the right of the insured. As per Ext.A1 document the complainant was admitted in hospital due to fever, nausea and headache and he was diagnosed for lower respiratory track inspection and type II DM. Ext. A3 document would show that the complainant had incured expenses of Rs. 15,000/- for his treatment. The Commission consider that the first opposite party cannot dictate terms of treatment. The complainant had hospitalised and undergone treatment on the basis of advice given by a qualified medical practitioner. Hence the first opposite party cannot thwart the legal claim of the complainant in an unreasonable manner and without any basis. The act of the first opposite party is amounted to deficiency in service.
8. There is no evidence adduced by the complainant to show that the second and third opposite parties were involved in the act of repudiation done by the first opposite party. Moreover there is no document to show that the second and third opposite parties were negligently treated the demand of the complainant. So the second and third opposite parties are exonerated from liabilities.
9. Point No.(ii)
The Commission find that the first opposite party is liable to reimburse Rs.15,000/- after considering Clause 9.5 of policy. The complainant did not challenge validity of clause 9.5 of the policy embodied in Ext.B1 document. As per Clause 9.5 of the policy each and every claim under the policy shall be subject to a Co-payment of 5% applicable to claim amount admissible and payable as per the terms and conditions of the policy. The amount payable shall be after deduction of the Co-payment. Hence the first opposite party is at liberty to consider the above clause if applicable to the claim of the complainant. It has come out in evidence that the complainant had submitted claim application for availing insurance benefit for treatment. But the first opposite party declined the same. The complainant was discharged from hospital on 07/09/2022. The repudiation letter was issued on 25/11/2022. The complaint was filed on 06/05/2023. The Commission finds that a considerable delay occurred on the part of the first opposite party in disbursement of insurance benefit. So the first opposite party is liable to reimburse treatment expenses along with interest at the rate of 9% per annum from the date of filing of this complaint. The act of non-disbursement of treatment expenses caused mental agony and inconvenience to the complainant. Hence the first opposite party is liable to pay a reasonable amount to the complainant as compensation to pacify his sufferings. The Commission consider that the first opposite party is liable to pay Rs. 20,000/- as compensation. Moreover the first opposite party is also liable to pay Rs. 10,000/- as cost of the proceedings. On the basis of above made deliberations the Commission allow the complaint in the following manner.
- The first opposite party is directed reimburse the expenses incurred for treatment as per Ext.A3 document after deducting the amount as per Clause 9.5 of the policy condition if applicable along with interest at the rate of 9% per annum from 06/05/2023 onwards.
- The first opposite party is directed to pay Rs. 20,000/- (Rupees twenty thousand only) to the complainant as compensation for the sufferings of mental agony and inconvenience.
- The first opposite party is directed to pay Rs. 10,000/- (Rupees ten thousand only) to the complainant as cost of litigation.
The first opposite party shall comply this order within 30 days from the date of receipt of copy of this order otherwise entire amount shall carry interest at the rate of 9% per annum from the date of this order till the date of realisation.
Dated this 30th day of October, 2024.
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.A1 to A4
Ext.A1: Discharge summary dated 07/09/2022 issued from NIMS hospital,
wandoor which shows treatment for lower respiratory tract inspection
and type II DM by the complainant.
Ext.A2: Copy of policy schedule issued in favour of the complainant and his wife
by the first opposite party which covered the period between 06/12/2021
and 05/12/2022.
Ext A3: Copy of discharge bill dated 07/09/2022 for Rs. 15,000/- by the NIMS
hospital, Wandoor.
Ext A4: Copy of repudiation letter dated 25/11/2022 issued by the first opposite
party.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1 to B3
Ext.B1: Copy of policy schedule along with its terms and conditions.
Ext.B2: Copy of discharge summary dated 07/09/2022 issued from NIMS
hospital, wandoor .
Ext.B3: Copy of repudiation letter dated 25/11/2022 issued to the complainant.
MOHANDASAN.K, PRESIDENT
PREETHI SIVARAMAN.C, MEMBER
MOHAMED ISMAYIL.C.V, MEMBER
