SMT. MOLYKUTTY MATHEW : MEMBER
This is a complaint filed by the complainant U/S 35 of Consumer Protection Act 2019 for an order directing the opposite parties to pay an amount of Rs.80,010/- to the complainant with interest @12% from 13/12/2022 till realization and to pay Rs.1,00,000/- compensation for mental agony of the complainant and cost for the deficiency of service on their part.
The case of the complainant in brief
The complainant is the policy holder of OPs bearing No.37628149. As per the policy conditions the OPs offered the complainant coverage of 7 lakhs as cashless scheme in case of the complainant’s admission of hospital and treatments. During December 2022 complainant consulted to Justice K S Hegde Charitable hospital, Mangalore due to pain of left hip rotation. After examination doctor found that the complainant is suffering due to left hip Avascular Necrosis and advised a surgery. Since the OPs policy covers and OPs offered cashless scheme in the hospital, the hospital authorities sent a proposal for the same to the OP vide dated 13/12/2022 for a total expected cost of Rs.1,25,000/-. On the same day OP send a reply vide letter No. AL No.80867313 and enquired personal history of the complainant, exact duration, past history of ailment, pain treatment records etc. Then the complainant prepared for a surgery. But the OP repudiated the proposal with a wrong finding that 2 year waiting period is necessary for the treatment of Arthritis, (if non ineffective) osteoarthritis and osteoporosis, Gout, Rhematism & spinal disorders, joint replacement surgery. Arthroscopic knee surgeries/ACL reconstruction/meriscal & ligament repair etc. As per the opinion of medical expert complainant’s disease is left hip Avascular Necrosis and not a disease mentioned in OP’s denial letter dated 15/12/2022. The medical records also shows that the said disease is not a pre-existing one. The complainant need a surgery in emergency, on 17/12/2022 he underwent his surgery and he discharged on 19/12/2022 and he was constrained to pay an amount of Rs.80,010/- for his discharge bill. Being the insurer the OPs are liable to reimburse the amount to complainant. The OPs repudiated the claim with a wrong finding that it is a pre-existing one and 2 year waiting period is necessary after the commencement of the policy. The act of OPs the complainant caused much mental agony and financial loss. So there is deficiency of service and unfair trade practice on the part of OPs. Hence the complaint.
After filing this complaint notice issued to both OPs. Both OPs received the notice. But they are not appeared before the commission and not filed version. As such this case came to be proceed against the OPs as set ex-parte.
On 10/05/2023 the OPs’ counsel filed vakkalath and petition to review the ex-parte order. But the Hon’ble commission dismissed IA No.124/23 as dismissed in limine, as the commission does not have power to set aside the ex-parte order.
Even though the OPs have remained ex-parte it is for the complainant to establish the allegations made by them against the OPs. Hence the complainant was called up on to produce evidence in the form of affidavit and documents. Accordingly the complainant has chosen to produce his affidavit along with 10 documents marking them Ext.A1 to A10. The complainant was examined as Pw1. So the OPs remain absent in this case. At the end the commission heard the case on merit.
Let us have a clear glance at the relevant documents of the complainant. Ext.A1 is the request for cashless hospitalization for medical insurance policy. Ext.A2 is the reply letter dated 13/12/2022 to additional information required for pre-authorization request. In Ext.A3 is the preparation for surgery and the copy dated 13/12/2022. In Ext.A3(a) is the repudiation letter dated 15/12/2022 that the cashless hospitalization cannot be approved as per terms and conditions of the policy. In Ext.A4 is the certificate issued by Dr.Vikram Shetty dated 15/12/2022 to certify that this cannot be pre-existing position. Brand on MRI finding also It may put around 2 months (early stage). In Ext.A5 is the discharge summary. In Ext.A6 is the inpatient bill. Total amount of Rs.80,010/-. InExt.A7 is the lawyer notice. Ext.A8 postal recceipt. Ext.A9 Acknowledgment card, Ext.A10 is the reply notice send by OPs. The OPs admitted the policy and the bounden duty of OPs to redress the grievance caused to the complainant. So the OPs are liable to refund the bill amount of Rs.80,010/- to the complainant. There is deficiency of service and unfair trade practice on the part of OPs. So the complainant is entitled to get the inpatient bill of Rs.80,010/- along with compensation of Rs.8,000/- as mental agony of the complainant and Rs.2,000/- as litigation cost.
In the result the complaint is allowed in part directing the opposite parties jointly and severally liable to refund the cash bill Rs.80,010/- to the complainant along with Rs.8,000/- as compensation for mental agony of the complainant and Rs.2,000/- as litigation cost within 30 days of receipt of this order. In default the amount of Rs.80,010/- carries 9% interest per annum from the date of order till realization. Failing which the complainant is at liberty to execute the order as per the provisions of Consumer Protection Act 2019.
Exts.
A1- Copy of application dated 13/12/2022
A2- Reply letter dated 13/12/2022
A3-Preparation for surgery and the copy dated 13/12/2022
A3(a)- Repudiation letter
A4-Certificate issued by Dr.Vikram Shetty dated 15/12/2022
A5-Discharge summary
A6-In patient cash bill
A7-Copy of Lawyer notice
A8- Postal receipt
A9-Acknowledgment card
A10-Reply notice
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
(mnp)
/Forward by order/
Assistant Registrar
