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

DATED 22^nd DAY OF FEBRUARY 2022

ORDER

SRI.K.S.BILAGI, PRESIDENT

1. The complaint has been filed under Section 35 of C.P.Act (hereinafter referred as an Act) against the OP for the following reliefs against the OP:-

(a) Direct the OP to settle the claim of Rs.81,623/- as agreed in the policy.

(b) Direct the OP to pay a sum of Rs.2,50,000/- as damages to the complainant for the medical agony, pain and sufferings, suffered by the complainant due to delay action and inaction of the OP.

(c) Award cost and litigation expenses.

(d) Pass such other direction that this Hon’ble Forum deems fit to grant in the interest of justice and equity.

2. The case set up by the complainant in brief is as under:-

The complainant took the insurance policy bearing No.P/141115/01/2020/009480 from 11.02.2020 to 10.02.2021 by paying premium of Rs.11,942/-. The complainant fell ill due to Covid positive.  Therefore, she took treatment in Fortis Hospital, Nagarabhavi, Bengaluru from 01.08.2020 till 05.08.2020.  But, Op refused to provide cashless facility, even though there is a clause in the policy.  Subsequently, the complainant make a claim for payment of Rs.81,623/- towards medical expenses.  But, OP without any valid reason repudiated the claim.  Despite legal notice dated 26.11.2020, the OP failed to pay the medical expenditure with interest.  This act of the OP amounts to deficiency of service.  Hence, this complaint. 

3. In response to the notice, OP appears and files version. The cashless claim was denied by repudiating the claim on 07.09.2020.  But, subsequently, as per the terms of the policy, an amount of Rs.53,891/- is settled in favour of complainant on 11.01.2021.

4. The following hospital expenses are disallowed namely;

(1) as per coverage clause (1) of Section 1 Rs.17,500/- is not allowed.

(2) as per excluded items of the policy and IRDA guidelines, the expenses towards RMO charges Rs.2,400/- is not payable.

(3) as per NABL rate dimer Rs.4,280/- is not payable. 

(4) The amount of Rs.2,100/- is not payable and hospitalization expenses of Rs.3,450/- is not payable.

Therefore, complainant was not entitled to Rs.29,731/- out of the claim amount of Rs.75,872/-.

4. There is no deficiency of service.  The complainant is not entitled to Rs.81,623/- towards hospitalization expenses and Rs.2,50,000/- as compensation.  The OP request to dismiss the complaint.

5. The complainant has filed her affidavit evidence and relies on 11 documents.  Affidavit of evidence of official of OP has been filed and OP relies on 11 documents and letter dated 11.06.2021. 

6. Heard the arguments of advocate for the complainant only.  No oral argument is advanced on behalf of OP.  Perused the written arguments.

7. The following points arise for our consideration as are:-

1. Whether the complainant proves deficiency of service on the part of OP?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

8. Our answers to the above points are as under:

       Point No.1:  Affirmative in part

      Point No.2: Affirmative in part

      Point No.3: As per final orders

REASONS

9. Point Nos.1 and 2:  Both the parties have reiterated their respective contention in their affidavit evidence.  The documents relied by both the parties are not in dispute.  Document No.1 is the identity card issued by OP in favour of Mr.Pavan Prakhyathan.N.  Document No.2 is the policy issued in favour of the complainant for sum insured amount of Rs.5,00,000/-.  The policy was in force from 11.02.2020 to mid-night of 10.02.2021.  Pavan Prakhyathan.N is the grand son of the policy holder.  The payment of insurance premium of Rs.11,942/- is not in dispute. Even though, there is a provision for cashless treatment.  But, OP has denied the cashless facility by letter dated 05.08.2020.  However, an opportunity is given to the policy holder that policy holder may however submit documents seeking reimbursement of the expenses incurred relating to the treatment of the disease.  Document No.6 indicates that the customer care has send mail to the complainant stating that as per the cashless issued by the Government of India, the patient was to take treatment under home quarantine and admission of patient was unnecessary.  But, such guidelines are not produced before us.  If really there was such guidelines, we failed to understand what made OP to reimburse the part of the claim amount of Rs.53,891/-.  Document No.7 indicates that the complainant was hospitalized in Fortis Hospital for the period from 1^st August, 2020 till 5^th August, 2020.  The discharge summary clearly indicates that patient was admitted to the hospital with history of Covid-19 positive.  Accordingly, treatment was provided. However, complainant/patient got discharged from the hospital against the medical advice.  However, the home quarantine for 10 days was suggested to the complainant.  The document No.8 indicates that complainant has spent in all Rs.75,872/-. Whereas, the complainant has further incurred expenses of Rs.5,750/- on 30.07.2020 before admission. Despite legal notice dated 26.11.2020, the OP failed to reimburse the medical expenses.  This notice came to be served on the OP.
10. The OP relies on certain documents and contends that a cheque for Rs.53,891/- dated 11.01.2021 has been accepted by the complainant. This payment is subsequent to filing the complaint. The complainant also refers in para 10 of her affidavit evidence that the OP unilaterally taken decision to transfer Rs.53,891/-.  If the document produced by the complainant are taken into consideration, the complainant has spent Rs.75,872/- and Rs.5,750/-, there is one rupee different.  In view of the payment of Rs.53,891/- balance remains Rs.27,732/-. 
11. The OP disallowed the claim of Rs.29,731/- referring the terms, IRDA guidelines, NABL rate dimer and other procedures.  Therefore, it is necessary to refer the document produced by the OP.  Annexure-B1 is the proposal form.  There is no dispute.  Annexure-B2 dated 18.01.2020 is the thanks giving letter by the OP to the complainant.  Document No.3 is the terms and conditions of the policy.  According to heading coverage Section 1(1) of the policy room (single standard A/c room) boarding and nursing expenses as provided by the Hospital/nursing home. In entire policy, there is no restriction about payment of hospitalization expenses under the head room and nursing.  Therefore, deduction of Rs.17,500/- is not correct.  The OP is liable to pay Rs.17,500/- towards room boarding and nursing expenses to the complainant.  Even though, OP refers certain items are excluded as per the terms of policy and IRDA guidelines.  But, IRDA guidelines, NABL rate of dimer and other procedure for disallowing the amount is not explained by the OP.  The OP has not produced IRDA guidelines, NABL rate dimer to accept the case of the OP about disallowing the certain expenses.  The OP also deducted Rs.3,450/- towards hospitalization expenses quoting NABL.  But this price list is not placed before us in order to upheld the contention of the OP.  The OP is not right in disallowing the expenses to the tune of Rs.27,732/-.  The OP is liable to pay balance amount of Rs.27,732/- within 60 days from the date of filing the complaint, the OP reimbursed Rs.53,891/-.  The non-payment of balance of Rs.27,732/- amounts to deficiency of service on the part of OP.  OP is liable to reimburse Rs.27,732/- balance amount to the complainant.
12. The complainant claims Rs.2,50,000/- as compensation. This claim has neither tail nor head and basis.  The purpose of the C.P.Act is not to provide unnecessary gain to the complain.  Under such circumstances, it is proper to award Rs.10,000/- as compensation as amount reimbursable is only Rs.27,732/-.
13.      Point No.3:- In view the discussion referred above, the OP is liable to pay balance amount of Rs.27,732/-, Rs.10,000/- as compensation and Rs.5,000/- as cost of litigation to the complainant. We proceed to pass the following 

  O R D E R

1. The complaint is allowed in part.
2. The OP shall pay balance amount of Rs.27,732/- with compensation of Rs.10,000/- and Rs.5,000/- as cost of litigation to the complainant. 
3. The OP shall comply this order within 60 days from this date, failing which the OP shall pay interest at 8% p.a. after expiry of 60 days on Rs.27,732/- till final payment.
4. Furnish the copy of this order and return the documents to the complainant with extra pleadings.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 22^nd day of February, 2022)

Documents produced by the Complainant which are as follows:-

Documents produced by the OP which are as follows:-