Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No.72/10.04.2018
Ayush Lamoria son of Shri Pramod Lamora
House no.3273, Sector 57, Gurugram
Haryana – 122001 …Complainant
Versus
OP- Max Bupa Health Insurance Company,
B-1,I-2, Mohan Cooperative Industrial Estate,
Mathura Road Block-e New Delhi-110044.
Branch - 39, 3rd Floor, Pusa Road,
WEA Karol Bagh, New Delhi-110005 ...Opposite Party
Date of filing: 10.04.2018
Coram: Date of Order: 04.06.2024
Shri Inder Jeet Singh, President
Ms. Rashmi Bansal, Member -Female
ORDER
Inder Jeet Singh , President
This case is scheduled for Orders (item no.16).
1.1. (Introduction to dispute of parties) - The complainant/Insured has grievances of unfair trade practice and deficiency of services against OP firstly - there was sanction of pre-authorisation for cashless facility for medical bills in respect of treatment of his mother Smt. Usha Lamoria but amount was not released and subsequently by declining reimbursement of medical bills of hospitalisation, pre-operative and post-operative medical expenses (within time limits) despite it were covered under Medi-claim Insurance Policy, on the pretext of concealment of facts of previous ailment/wrong declaration in proposal form besides insurance policy was also cancelled; OP has invoked clause no. 4 of the policy. Whereas, the complainant had disclosed previous ailments of her mother, nothing was concealed; her parents were put to rigorous medical tests and examination before the policy was issued. The complainant also protests other acts of OP of denial of valid claim & cancellation of policy being illegal and without substance.
The complainant seeks reimbursement of medical bills of Rs.1,55,715/- of pre-hospitalisation (60 days); bills of Rs.1,81,351/- of post-hospitalisation (90 days) and reimbursement of other medical expenses of hospitalisation etc for Rs.7,29,664/- (in respect of claim nos. 301936 dated 28.12.2017 and 303113 dated 04.01.2018) along-with interest at the rate of 24% pa, compensation of Rs.5,00,000/- on account of harassment , mental agony and sufferings, apart from litigation costs of Rs. 50,000/- and other appropriate relief under the circumstances.
1.2. The OP opposes the complainant by denying allegations of deficiency of services and OP also justifies withdrawal of pre-authorisation and repudiation of claim and cancellation of policy. The pre-authorised and then subsequent claims were properly declined as the complainant had suppressed material facts of previous ailment existing prior to inception of policy, besides the year of ailment in respect of disclosed ailment was by wrong declaration in the proposal form. Policy was also properly cancelled. in terms of policy condition, since the complainant suppressed and failed to disclose pre-existing diseased. The policy was obtained by misrepresentation and against the principles of utmost good faith. The exclusion clause 4A of the policy applies. It cannot be construed deficiency of services and complainant is not entitled for any claim/relief.
1.3. It is relevant to mention at this stage that the OP had filed written statement to oppose the complaint, however, the reply/written statement is not signed and verified by any person of OP. The paragraph-C of the written statement mentions that Ms. Chandrika Bhattacharya was authorized by the OP to protect the interest of OP and for filing documents, reply and representation, however, that authorization has not been filed with the written statement despite mentioning so.
Moreover, the complainant in his replication vehemently opposed that the written statement for want of its signing and verifying, that too without any authorization, is not the pleading to be read. There was no explanation by the OP throughout in the subsequent record to meet the objection of complainant.
2.1. (Case of complainant) –The matrix of the case of the complainant as set up in the complaint is, briefly, that complainant browsed website of OP, after the complainant was approached by an agent of the OP, which revealed that the OP is an insurance company of repute, which handle the insurance policies as well as the claim are settled at high percentage. The complainant was approached by the agent of OP for issue of Family first silver plan/insurance policy. It was also assured that in case of medical need, there will be cashless claim facility. Thus, believing that agent and other circumstances surfaced, the complainant decided to buy family first silver plan for his mother and father. The complainant’s mother and father were put to undergo various medical tests and examinations by the OP to check for existing ailments and other conditions; their vitals were within the prescribed level and there was no hort of disease, ailment or other condition.
While filing the form for insurance policy, complainant’s mother Smt. Usha Lamoria disclosed to the agent of OP that she is diabetic since 2007, however, the said agent told that as per policy definition, the pre-existing disease means any ailment or injury or related condition which was within 48 months prior to policy coming into existence and year 2007 was not under such time frame. The said agent had requested complainant’s mother to provide recent date on which either she was diagnosed or had undergone any treatment. As such, complainant’s mother was stable since 2007 about diabetic condition and year 2011 was mentioned in the said form since she had medical check –up in that period but the year 2011 mentioned was changed later on to 2012 by the agent in the proposal form, without complainant’s knowledge besides signature on such correction do not belong to complainant.
2.2. The complainant bought said family first silver insurance policy for his mother and father for sum insured of Rs. 17 lakhs against payment of premium of Rs. 24,730/- vide policy no. 30276637201300 on 03.12.2013 after completion of extensive verification tests and formalities. The policy has been renewed from time to time and there was no premium default by the complainant.
2.3 In 2014 the complainant’s mother (while going through regular check-up/tests) was diagnosed with chronic kidney disease (CKD), for which medication and treatment were started; her condition was stable. But in the end of November 2017 her condition was deteriorated and kidney transplant was advised by the doctors. The complainant’s father was a suitable donor as his kidney matched to the requirement of complainant’s mother, therefore, the complainant applied for pre-authorization request for and amount of Rs. 3,58,870/-, which was approved by the OP on 07.12.2017. She was issued discharge summary.
2.4 On 10.11.2017 Smt. Usha Lamoria was admitted for pre-operated anesthesia evaluation in Aremis Health Institute, Gurgaon (briefly referred as Hospital) and she was again admitted in that hospital on 29.11.2017 for pre-operative procedure and pre-operative dialysis, she was discharged on 01.12.2017. She was issued discharge summary.
On 07.12.2017 she was admitted in the hospital for transplant procedure and after completion of transplant procedure; she was advised get discharged on 21.12.2017. The complainant get his mother discharged on 21.12.2017 after successful transplant as well as under the believe that there was already pre-authorization and the complainant will be reimbursed the hospital expenses; discharge summary was issued by the hospital on this occasion also. The complainant had borrowed the money from his friends and family besides using credit card to pay the hospitalization bills while getting discharged his mother.
2.5 The complainant applied for reimbursement of paid bills by claim no. 301936 dated 27.12.2017 and claim no. 303123 dated 04.01.2018 but the OP had rejected the claims of the complainant by letter dated 06.02.2018 on the false reasons that she has pre-existed CKD since July 2013 and diabetics since 2007, stated to be not disclosed in the proposal form; whereas, there was pre-authorization on 07.12.2017 by the OP. Moreover, claim for dialysis amount was also refused by the OP on the ground it is ongoing procedure but in fact it was part of kidney transplant and not a separate procedure. The OP had rejected the claim that in the discharge summary of hospital the date of diagnosis of CKD was mentioned as 15.03.2013 but it was wrongly mentioned by typographical error instead of actual date of 15.03.2014, which was rectified by the hospital and the same was also notified to the OP. As per Clause-6/definition.41 “Pre-existing disease means any condition, ailment or injury or related conditions(s) for which the insured person had signs or symptoms, and/or were diagnosed, and/or received medical advice/treatment, within 48 months prior to the first policy issued by us”. Hence, CKD was not a pre-existing ailment but it was diagnosed in 2014 after inception of the policy and diabetes was already disclosed to the respondent. The OP had allowed pre-authorization request previously and based on the same, the complainant paid hospital expenses believing that it will be reimbursed and the bills amount was paid by the complainant. At the time of taking insurance policy, the complainant was given assurances for hassle free service including cashless claim, reimbursement of bills etc. The complainant had spent Rs. 1,55,715/- on pre-hospitalization (for 60 days) and Rs. 1,81,351/- on post-hospitalization expenses (for 90 days). The acts of OP are malicious with intention to cheat the complainant as genuine and bona-fide claims were rejected. Moreover, the OP by its email dated 07.02.2018, while relying upon clause no. 3 of policy terms and conditions, wrote the insurance policy would be cancelled due to not disclosure of pre-existing ailments/medical condition while taking the insurance policy. The complainant sent legal notice dated 22.02.2018 to the OP to process the valid claim of complainant but OP did not bother to reply the legal notice. Whereas, the claim being genuine and valid claim, the OP was under obligation to pay the genuine claim, therefore, for want of such settlement of claim, it is unfair trade practice, for which complainant suffered inconvenience, financial hardship, harassment, mental agony and reputation loss. There is also deficiency of services. That is why the present complaint for relief claimed.
2.6. The complaint is accompanied with copies of - printout of OP's website browsed, insurance policy, pre-authorization request approval, discharge summary dated 10.11.2017, discharge summary dated 01.12.2017, discharge summary dated 21.12.2017, claim form dated 27.12.2017, rejection letter dated 06.02.2018, hospital bills and receipts, pre-hospitalization and post hospitalization bills , email dated 07.02.2018 and legal notice.
3.1 (Case of OP)- The stand of OP is already introduced in paragraph 1.2 above. Further, issue of policy is not opposed by the OP but claim is opposed. Briefly, as per medical treatment record, it clearly states that Smt Usha Lamoria was suffering from diabetes mellitus type-2 since 2007, CKD 2014, hypothyroidism since 2016 and several other health complications related to DM-2 and CKD. The claim was repudiated since there were false and misleading statements and assertions by the complainant vis-à-vis the insurance contract is contract of utmost good faith, every material fact must be disclosed otherwise there is a good ground for recession of the contract. At the time of inception of the policy, the complainant made false declaration that insured was suffering from diabetes since 2012, but it was existing since 2007.
The complainant never approached the OP that any information given in the document in the policy kit was incorrect or any terms thereof are not acceptable to him, therefore, the complainant is strictly bound by the terms and conditions of the policy. The clause 4A is of exclusions, which reads as - “4. Exclusions - we shall not be liable under this policy for any claim in connection with or in respect of the following :-
Pre-existing disease - Benefits will not be available for pre-existing diseases :
(i) for Gold and platinum plans only, until 24 months of continuous coverage have elapsed since the inception of the first policy with us;
(ii) For Silver plan, until 48 months of continuous coverage have elapsed since the inception of the first policy with us.
(iii) Where the policy is renewed for enhanced sum insured, waiting periods would start afresh for the amount of increase in sum insured.
Thus, the claim of complainant was rightly repudiated on these conditions. The reimbursement of the claim was denied with the reason “pre-existing diseased was not disclosed by the complainant at the time of inception and availing the policy”. The complainant had requested for dismissal of the complaint, for want of deficiency of services or otherwise.
3.2. The written statement is accompanied with - copy of letter dated 07.2.2018, 28.02.2018 and medical report/discharge summary dated 21.12.2017, investigation report and none else. [no authority letter mentioned as R1 was annexed (to sign, verify and file the written statement); the written statement is not signed by anyone. [the OP has referred case law in the written statement, however, it will be referred as appropriate stage of this final order].
4. (Replication of complainant) – The complainant filed detailed replication to oppose reply vehemently, firstly written statement cannot be read for want of mandatory signature and verification of authorized person vis a vis no authority letter was filed. The allegations of written statement are opposed and the complaint is reaffirmed as correct. The clause 4A being relying upon by the OP in its written statement is not so in the terms and conditions provided to the complainant and it is clause 4, which has already been mentioned in the complaint.
5.1. (Evidence)- In order to establish the complaint, the complainant Sh. Ayush Lamoria filed his exclusive affidavit of evidence with the support of document filed with the complaint.
5.2. On the other side, OP led evidence by filing affidavit of Ms. Chandrika Bhattacharya, attorney of OP. The affidavit is supported by 13 documents [whereas 13 documents were not filed written statement nor any formal permission was taken to file the documents at such belated stage].
6.1 (Final hearing)- Both the parties have filed their written arguments. At the stage of oral submissions, Sh. Ricky Chopra Advocate and Ms Snigdha Lal, Advocate for complainant and Sh. Suman Tripathi, Advocate and Ms Shruti Mishra Advocate for OP presented their respective submissions
6.2. In order to fortify the contentions, the OP derives reasons for the following cases:-
(a) Satwant Kaur Sandhu Vs.New India Assurance Co. Ltd. (2009) 8 SCC 316-
'when information on a specific aspect is asked for in the proposal form, the assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. Obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known.
Whether the information sought for is material for the purpose of the policy is a matter not to be determined by the proposer.
(b) Mrs. Shnyni Valsan Pombally Vs. State Bank of India RP. No. 3947/2013, wherein it was held that contract of insurance is based on the principle of utmost good faith, which applies to both sides. The rule of non-disclosure of material facts vitiating a policy still holds the field.
(c) P C Chacko & antr Vs Chairman, LIC Ltd (AIR 2008 SC 424), held that contract of life insurance are contracts of utmost good faith, every material fact must be disclosed, otherwise there is good ground for recession of the contract. (further reference is also made to reported case in AIR 1992 Delhi 197, AIR 1994 SC853, I 1994 CPJ 425, I 1997 CPJ 94].
(d) Haji Ahmed Yar Khan vs Abdul Gani Khan (AIR 1937 Nag 207 at 272) it was held, three conditions are, the statement must be on material matter, or must suppress facts which it was material to disclose, the suppression must have known at the time of making the statement that it was false or that it was false or that it suppressed facts which was material to disclose.
7.1 (Findings)- The rival contentions are considered by taking into account stock of material and evidence of parties, the documentary record, case law presented. Their submissions need not to be reproduced, since the cases of parties have already been narrated in detail in paragraphs 2 and 3 above.
7.2. The complainant has raised a serious issue that for want of signing and verifying written statement by and on behalf of OP, it cannot be read vis-à-vis the OP has juxtaposition that all material documents referred are from the record of complainant too, which proves case of OP.
It is codified law under Order VI Rule 14 CPC that every pleading shall be signed by the party and his pleader, if any,. This provision is clear in itself that party has to sign and verify the pleading and in case there is pleader, it may also sign it in addition to the party. In other words, signature of party on the pleading is mandatory and signature of the pleader is not substitute of signature for the party; verification is to be the party. Since the written statement/reply is not signed by and on behalf OP therefore, in terms of Order VI Rule 14 CPC, the reply iv not valid in the eyes of law, it cannot be read. Simultaneously, the OP has been referring the documentary record of complainant filed with the complaint and in evidence, to oppose the claim of complainant, therefore, the same set of documents may be considered appreciating the case of the parties. With this preliminary observation, now the case on merits is being considered.
7.3. On the face of record, that the relationship of the complainant and of the OP are of the Insured and of the Insurer, complainant's mother is also insured, it is not disputed nor about the medi-claim policy issued from time to time, its tenure, total sum insured of Rs.17 lakhs, individual cover of Rs.1 lakh and premium paid. The proposal form furnished is also not disputed (except over-writing of year 2012 over the year 2011). The complainant's mother Smt. Usha Lamoria had under-gone pre-anesthesia test, pre-operative test and then medical treatment as indoor patient in the Hospital, the discharge summary issued on such occasion are also not disputed, besides the complainant had paid the entire medical bills.
The terms and conditions of the policy are also not disputed, the complainant has reproduced clause 4 of the insurance policy, which is based on the insurance policy filed vis-à-vis the OP has also filed insurance policy at later point of time, it also contains same clause 4, it depicts the same clause 4 as reproduced by the complainant instead of clause no. 4A as mentioned by the OP (in the unsigned written statement). Although, it was Family first silver policy, which is not a disputed fact.
7.4. But the consumer dispute is (1) 'whether or not the complainant's mother had pre-existing disease for the purposes of policy and she concealed it from the OP? (2) Whether or not the complainant is entitled for insurance claims and other reliefs? In order to determine such issues, it needs to analyse the evidence, whether there was pre-existing of disease for the purposes of obtaining policy and for want of its declaration, what consequences would flow under the terms and conditions of policy vis a vis exclusion clause would be applicable.
From that point of view to appreciate the rival case of parties, it is relevant to refer law laid down in "Jagdish Vs LIC of India [FA no.1055/2003 dod 17.12.2007, decided by Hon'ble State Commission]", in which circumstances and parameters of pre-existing disease were laid down in detail, its paragraph 10 is reproduced -
"Para 10 -Our conclusions on the meaning and import of words disease, pre-existing
disease for the purpose of medi-claim insurance policy, as under:
(i) Disease means a serious derangement of health or chronic deep-seated disease
frequently one that is ultimately fatal for which an insured must have been hospitalized or operated upon in the near proximity of obtaining the medi-claim policy,
(ii) Such a disease should not only be existing at the time of taking the policy but also
should have existed in the near proximity. If the insured had been hospitalized or operated upon for the said disease in the near past, say, six months or a year he is supposed to disclose the said fact to rule out the failure of his claim on the ground of concealment of information as to pre-existing disease,
(iii) Malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and
the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease,
(iv) If insured had been even otherwise living normal and healthy life and attending to
his duties and daily chores like any other person and is not declared as a diseased person as referred above he cannot be held guilty for concealment of any disease, the medical terminology of which is even not known to an educated person unless he is hospitalized and operated upon for a particular disease in the near proximity of date of insurance policy say few days or months,
(v) Disease that can be easily detected by subjecting the insured to basic tests like
blood test, ECG etc. the insured is not supposed to disclose such disease because of otherwise leading a normal and healthy life and cannot be branded as diseased person,
(vi) Insurance company cannot take advantage of its acts of omission and commission as it is under obligation to ensure before issuing medi-claim policy whether a person is fit to be insured or not. It appears that insurance Companies do not discharge this obligation as half of population is suffering from such malaises and they would be left with no or very little business. Thus any attempt on the part of the insurer to repudiate the claim for such non-disclosure is not permissible, nor is exclusion clause invoke-able,
(vii) Claim of any insured should not be and cannot be repudiated by taking a clue or
remote reference to any so-called disease from the discharge summary of the insured by invoking the exclusion clause or non-disclosure of pre-existing disease unless the insured had concealed his hospitalization or operation for the said disease undertaken in the reasonable near proximity as referred above,
(viii) Day to day history or history of several years of some or the other physical problem
one may face occasionally without having landed for hospitalization or operation for the disease cannot be used for repudiating the claim. For instance an insured had suffered from a particular disease for which he was hospitalised or operated upon 5, 10 to 20 years ago and since then had been living healthy and normal life cannot be accused of concealment of pre-existing disease while taking medi-claim policy as after being cured of the disease, he does not suffer from any disease much less the pre-existing disease,
(ix) For instance, to say that insured has concealed the fact that he was having pain in
the chest off and on for years but has never been diagnosed or operated upon for heart disease but suddenly lands up in the hospital for the said purpose and therefore is disentitled for claim bares dubious design of the insurer to defeat the rightful claim of the insured on flimsy ground. Instances are not rare where people suffer a massive attack without having even been hospitalised or operated upon at any age say for 20 years or so,
(x) Non-disclosure of hospitalization/or operation for disease that too in the
reasonable proximity of the date of medi-claim policy is the only ground on which insured claim can be repudiated and on no other ground.
7.5. As appearing there is dispute of pre-existing disease and its concealment in the proposal form, both the issues are related with each other, they are required to be analysed together, that is why both are being taken together. By considering facts, features, evidence of parties along-with the settled law, the following conclusions are drawn:-
(i) The proposal form has been proved by the complainant, it mentions that Smt. Usha Lamoria was patient of diabetes and she was on medication of one tablet every day. This proves that she has disclosed about her previous ailment of diabetes in the proposal form and it was not concealed by her.
However, corresponding diabetes, it mentions year 2012 and there is overwriting on of last digit ‘2’ and the complainant has explained that it was 2011, which was corrected by the agent of OP by mentioning it as 2012 of his own, without the knowledge of complainant. There is no defence of OP to counter this fact narrated by the complainant.
In addition, the mentioning of year 2011 or 2012 or want of mentioning of year 2007 would not give any benefit to the OP, since ailment of diabetes of Smt. Usha Lamoria was declared in the proposal form besides other particulars, she was put to various medical tests and examination before taking decision by OP for issuing the subject insurance policy in the year 2013. After taking cognizance of such circumstances declared ailment, medical reports and tests got done by the OP, then premium was accepted and policy was issued. Now OP cannot take stand of wrong declaration on the pretext of year. The case presented on behalf of OP is distinguishable from the features of this case.
(ii) According to OP, the insured Smt. Usha Lamoria was known case of CKD prior to policy inception; the policy was issued in the December 2013. It means according to OP she was known patient of CKD prior to 2013. However, the plea of OP does not sustain in view of discharge summary dated 21.12.2017 (page no. 91 of the paper book) mentioning past medical and history that CKD is diagnosed since 2014. This negates the plea of OP. There was no reason for the insured to make declaration about CKD in the proposal form since Smt. Usha Lamoria was diagnosed of CKD subsequently in 2014, much after proposal form and issue of insurance policy/plan.
(iii) In view of the sub clauses (i) & (ii) above, it does not make out the case of concealment of pre-existing disease of wrong declaration.
(iv) When there was no concealment of pre-existing disease/condition nor there was any wrong declaration, therefore, cancellation of policy by OP was wrong, improper and unjustifiable.
Consequently to make it right, proper and justified, the insurance policy is restored.
(v) It also flows the claim was improperly declined on such reasons. Moreover, it does not satisfy the exclusion clause as mentioned in the terms and conditions of the policy. The complainant is entitled for valid medical claims and expenses.
7.6.1. The complainant has proved the medical bills of pre-authorization medical expenses, post-hosptialisation bills as well as other expenses during hospitalization. Ld. Counsels for the OP has pointed out that there are many various type of insurance plan but complainant has opted for 'silver plan', which entitles for 'share basis room' that too hire limit of 15% individual cover of Rs.1,00,000/- and not 'single basis' but the patient-insured had opted single basis and paid higher hire. The other expenses are to be reduced proportionately by 15%.
The complainant opposes it since there is no proof of such facts, figures and material to decline the proportionate claim and OP's claim is not tenable.
7.6.2. It is matter of proved record, that the insurance policy was family first silver plan [for Sum Insured of Rs.15 lakhs +individual cover Rs.1 lakhs + Rs 1 Lakh], which prescribes cap of shared room and it covers upto 15% of sum insured. The complainant had availed single occupancy room having hire of Rs. 7,700/- each day for 29.11.2017 & 30.11.2017 and single occupancy room having hire of Rs. 9,400/- for each day from 17.12.2017 to 20.12.2017. The total amount spent room hire was Rs. 43,600/- whereas, the individual cover for Smt. Usha Lamoria was of Rs. 1 lakh, its 15% comes to Rs. 15,000/-, for which she is entitled. Therefore, she was not entitled for remaining amount of Rs. 28,600/-, it is to be deducted from Rs.43,600/-.
7.6.3. So far other hospitalisation expenses are concerned, they are under various headings, including pharmacy. How, it is to be reduced proportionately by 15% is not proved by OP. The pre-hospitalisation and post hospitalisation expenses claimed are within the prescribed time limit under the policy.
7.6.4. Thus, the facts on record proves case of complainant that he lodged valid medical claims of amount viz (i) pre-operative medical expenses of Rs.1,55,715/- (ii) medical bills amount of Rs.7.01,064/-during hospitalisation (after deducting Rs.28,600/- from claimed amount of Rs.7,29,664/-) and (iii) post - operative medical bills/expenses of Rs.1,81,351/-. The complainant is held entitled for reimbursement of all such medical bills.
8.1. The complainant has sought interest at the rate of 24% pa, however, considering facts & features of case as well as complainant was deprived of valid claim, he had to part with money in paying medical bills and other expenses, therefore, interest @ 5% pa would be justified for both ends, interest will be computed from the date of complaint till realization of amount in favour of complainant against the OP.
8.2 The complainant has also sought damages of Rs.5,00,000/- towards harassment and agony. By considering totality of circumstances of case of both sides especially concluded in aforementioned paragraphs, since there was inconvenience, harassment to the complainant to secure his valid claim, even efforts were made through legal notice, therefore, complainant plea for entitlement for damages is justified, it quantified as Rs 20,000/- to this situation, accordingly it is allowed in his favour and against OP.
The complainant has also requested for other appropriate relief. Since the complainant had served advance legal notice but for want of settlement of claim,. he was constraint to file the complainant. It makes out his entitlement for costs, thus cost is determined as Rs.10,000/-in his favour and against the OP.
9. Accordingly, the complaint is allowed in favour of complainant and against the OP to reimburse (i) pre-operative medical expenses of Rs.1,55,715/- (ii) medical bills amount of Rs.7.01,064/- during hospitalisation and (iii) post - operative medical bills/expenses of Rs.1,81,351/-along-with simple interest @ 5%pa from the date of complaint till realization of amount; besides to pay (iv) damages of Rs.20,000/-and (v) costs of Rs.15,000/- to complainant.
OP is also directed to pay the amount within 45 days from the date of this order. In case amount is not paid within 45 days from today, then rate of interest will be 8% per annum (instead of 5%pa) on amount mentioned in (i), (ii) and (iii) above.
10. Announced on this 4th day of June 2024 [ज्येष्ठ 14, साका 1946]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances, besides to upload on the website of this Commission.
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