BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 31^ST DAY OF JANUARY 2023

ORDER

SMT. SUMA ANIL KUMAR, MEMBER

1. The  complainant No.1 & 2   have filed this complaint under section 35 of C.P.Act, 2019 against the Opposite party  for the reliefs

1. To direct the OP to reimburse the claim amount of Rs.3,42,060/- with an interest at 12% p.a. from the date of claim i.e.05.08.2020 till the realization.
2. To direct the OP to pay compensation for the delay in reimbursement of the claim.
3. To direct to pay Rs.5,00,000/- as damages for unnecessary harassing the complainant by asking to submit the same documents time and again.
4. To direct to pay cost of Rs.25,000/- and such other reliefs as this Hon’ble commission deems fit in the circumstances of the case and allow the complaint with cost in the interest of justice and equity.

2.  The brief facts of the case of the  complaints are as under:

The complainant No.1 & 2 have filed this complaint stating that  complainant no.1 has taken Health Insurance policy name “Care Senior NCB Super” bearing no.13167166 of the Rs.5,00,000/- in the name of his mother Smt.Gomathi  i.e. complainant no.2 on 12.10.2018  and policy is valid for 03 years i.e. from 12.10.2018 to 11.10.2021 with liable to indemnify the complainant with regard to entire medical expenses.

3. The complainant no.2 was admitted to Nano Hospital, Bengaluru on 10.07.2020 for treatment for Covid-19 as she was tested Covid Positive with serious condition, where she was treated as inpatient and discharged on 23.07.2020. The hospital has charged Rs.3,42,060/-, out of which Rs.3,34,000/- is charged for medical treatment, medicines, bed charges etc.  and Rs.8,060/- was the charges for Covid-19 test before admission to the hospital. The complainant has informed the OP on 30.07.2020 to pay andindemnify  the hospital bill and sent required documents on 17.08.2020 through DTDC Express courier but the OP  has not paid and sent a deficiency letter raising five queries on 19.08.2020. The complainant has replied  back by sending relevant documents asked by the OP on 25.08.2020.

4.  The complainant received many deficiency  letters asking for queries by the OP. i.e. on 04.09.2020, 19.09.2020 and 21.09.2020 respectively. The complainant replied on 23.09.2020 with relevant documents and continuously followed up with OP for reimbursement of amount, but he received a claim denial letter from the OP on 08.10.2020 saying that on non-disclosure of material facts at the time of proposal Hypertension and Dyslipidemia  prior to policy inception.

5. The complainant contacted the OP several times demanding the payment of amount. The OP  showed negligence and tried to escape from payment by giving reasons as  non-claimable. Hence, the complainant  had to file a complaint before this commission on 23.02.2021 through his advocate and sent notice to OP dt.24.11.2020. The treatment taken by the complainant falls well within the time period of the policy i.e.12.10.2018 to 11.10.2021. The OP has failed to pay the complainant as per the policy insured and hence played fraud and deficiency of service. The complainant has suffered mental agony, financial loss. Hence, the complainant filed this complaint.

6. After service of notice, OP has appeared before this commission through their counsel and files his version on 21.07.2022.  

The OP admits to the policy taken dt.19.11.2018 till 18.11.2021 for a sum of Rs.5,00,000/- issued to the complainant with also a latest policy   effective from 19.11.2021 till 18.11.2023 renewed by the complainant. The complainant  was approached for reimbursement of the claim No.91391177-00-01 for her hospitalization  at Nano hospital for Moderate Covid-19 infection with a discharge summary dt.22.07.2020.  OP has further asked for documents required such as seal and sign of treated doctor, package charges for covid case which is authorized by State Government dt.13.08.2020. OP has again asked for submission of exact duration of past history, present ailment, past treatment records, passport size photograph, doctor’s notes, Nurses notes etc. form the complainant dt.19.08.2020 and has received reply to the query by complainant dt.20.08.2020.

7. Further OP again has asked for first consultation paper of Dyslipidemia and other supportive reports dt.19.08.2020, 04.09.2020 and 14.09.2020. The OP further raised another query to the complainant dt.21.09.2020 seeking treating Doctor’s certificate justifying the prolonged/ need of  hospitalization. OP, as per discharge summary and critical assessment form of the hospital and an email dt.25.08.2020  received from the complainant initially rejected the reimbursement vide dt.09.10.2020 on grounds of non-disclosure of material facts at the time of proposed. Thereafter OP company vide deficiency letter dt.13.01.2021 and reminder letter dt.16.01.2021 and 19.01.2021 requested the complainant to submit consolidated final bill and original bill and first copy of consultation copy of Dyslipidemia  and again rejected the reimbursement claim vide denial letter dt.29.04.2021 on the grounds of deficiency not replied dt.13.01.2021, 16.01.2021 and 19.01.2021.

8. The OP submits that as per the policy terms and conditions clause-6, claim procedure and management and claim-6.2 claim settlement facilities and clause-6.3 duties of claimant, which say that the policy holder shall submit immediately and in an event within 15 days of insured members discharge. The company shall be provided with complete necessary documents such as duly filled and signed claim, Photo ID, Medical practitioners referred letter, prescribed drugs, diagnostic tests, consultation, original bills, discharge summary, pharma bills, operation theatre notes, indoor case paper,  original investigation test report etc. The OP duly acknowledges the legal notice received from the complainant on 24.01.2020 and replies on 18.01.2021 clearly mentioning the requisite documents required in order to process the claim of the complainant. Wherefore, it is prayed by the OP to dismiss the complaint with exemplary costs in the interest of justice and equity.

9. The complainants in order to prove their contentions, complainant no.1 has filed his affidavit evidence and produced documents, which are marked as Ex. P1 to P15.  Sri Harish.N.  Head of branch operations of OP has  filed his affidavit evidence and produced documents, which are marked as Ex.R1 to R12.

10. Heard the arguments of the counsel for complainant. No representation for arguments from OP.  

11.    The following points do arise for our consideration are as under:-

1. Whether there is deficiency in service on the part of the OP?
2. Whether the complainant is entitled for the reliefs as sought for?
3. What order?

12. Our answer to the above points are as under:

       Point No.1:-Affirmative

      Point no.2:- Affirmative in part.

      Point No.3:-As per the final order.

REASONS

13. Point Nos.1 and 2:. These two points are interrelated and hence they have  taken up for common discussion.

14. The complainant has filed his affidavit evidence by reiterating all the allegations made in the complaint as stated above.

15. He has relied on Ex.P1 to P15. Ex.P1 is copy of the Insurance policy taken by the complainant from OP and it is Care Senior Service NCB policy of Rs.5,00,000/- dt.12.10.2021. Ex.P2  contains of a documents  showing policy no., Member I.D. No., Admission form of Nano Hospital,  Doctor’s prescriptions, medical bills, X-ray reports, ECG report, Blood test report, Lab report of the complainant i.e. Smt. Gomathi. Ex.P3 is copy of the receipt of  DTDC Express courier sent by the complainant  dt.30.07.2020. Ex.P4 is the copy of receipt of DTDC express courier received by the OP dt.17.11.2020. Ex.P5 is copy of deficiency letter issued by OP to the complainant regarding needs for the claim. Ex.P6 is the copy of an email of the communications of the complainant and OP. Ex.P7 is the copy of the claim denial letter issued by OP to complainant dt.08.10.2020. Ex.P8 is the copy of the email from OP to complainant dt.17.09.2020. Ex.P9 is the copy of legal notice issued by counsel for complainant to OP dt.24.11.2020.Ex.P10 is the copy of the reply to the legal notice received dt.17.12.2020. Ex.P11 is the copy of the email communication of OP and complainant. Ex.P12 & P13 are the copies of certificates under section 65(B) of Evidence Act. Ex.P14 is copy of the bills of Nano hospital and Ex.P15 is a detailed bill of Nano Hospital which is amounting to Rs.3,34,000/-  and bill of the test done i.e. of Rs.7,140/-.

16. The OP has filed his affidavit evidence with documents marked as exhibits R1 to R12. The Ex.R1 is the copy of the insurance policy taken by the complainant from the OP dtd.12.10.2018. Ex.R2 is the discharge summary of complainant Smt.Gomathi issued by Nano Hospital. Ex.R3 & R4  are the copies of email sent by OP to the complainant dt.13.08.2020 and dt.19.08.2020, 04.09.2020 and 14.09.2020.  Ex.R5 is the copy of deficiency letter. Ex.R6 is the copy of query reply. Ex.R7 & R8 are copies of deficiency letters dt.21.09.2020. Ex.R9 is the reply of OP to notice issued by the complainant.

17.  It is clear from the Ex.P1 that the complainant has  mentioned about the patient i.e. his mother Smt.Gomathi’s previous medical history and medicines prescribed to her in the application while taking  the policy from OP and the OP  cannot  deny the claim on the basis of non-disclosure of material facts at the time of proposal as he has mentioned in the Ex.P1. The complainant has also informed the OP and has followed the procedures required  in time. The said admission of the complainant falls within the time period of the policy i.e. from 12.10.2018 to 11.10.2021. The complainant has regularly followed the instruction of OP for the claim and submitted all the documents required for claim such as blood reports, X-ray, tests, pharmacy bills, Doctor prescription, etc.

18. The OP denied the claim on different reasons on different occasions, which clearly shows the intention of the OP is  avoiding payment of the claim amount. The complainant has submitted all the bills produced by the hospital in Ex.P2 and has also produced a complete  detailed bills  issued by the hospital which clearly shows that the bill dt.22.07.2020  paid by the complainant  sum up to Rs.3,34,000/- for treatment of the patient and Rs.7,140/-+Rs.920/-=Rs.8,060/- for the tests conducted dt.09.07.2020 on the patient in Ex.P15 filed by the complainant. This clearly shows that the complainant had got admitted in the hospital for treatment of Covid-19.

19. The OP has been giving different reasons for non claim of the policy. Once the OP denies the claim on the terms as that complainant has not disclosed the facts while taking the policy and later denies the claim saying they want the copy of consultation paper of Dyslipidemia  of the patient. The OP has been informed about the Dyslipidemia and hypertension treatment taken by the complainant while taking the policy itself and there is no need to verify it now. This shows the wrong intention of OP to escape from the payment of claim which amounts to deficiency of service and unfair trade practice. Therefore, under these circumstances the complainant is entitled for the hospital claim,  also damages for mental agony,  financial loss and litigation expenses. Hence, we answer point no.1 in affirmative and  Point no.2 partly in affirmative.  

20. Point no.3:-.  In view of the above discussions, the complainant is liable to be allowed in part and entitled for Rs.3,42,060/- with interest at 10% p.a. from the date of complaint. The complainant is also entitled for compensation of Rs.30,000/- for financial loss, mental agony and litigation charges of Rs.10,000/-. Accordingly, we proceed to  pass the following 

O R D E R

1. The complaint is allowed in part.
2. The OP is directed to refund the amount of Rs. 3,42,060/- with interest at 10% p.a. on the date of complaint till realization.
3. The OP is further directed to pay compensation of Rs.30,000/- for financial loss, mental agony.
4. The OP is further directed to pay  Rs.10,000/- towards litigation expenses.
5. The OP is further directed to pay entire amount within 60 days from the date of this order, if the OP failed to refund the amount, the amount of  Rs.3,42,060/- will carry interest at 12% p.a. after expiry of 60 days  till realization of the amount.
6. Furnish the copy of this order to both the parties, and return the spare pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 31^st  day of January, 2023)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party – R.W.1:  

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