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

DATED 15TH DAY OF DECEMBER 2022

ORDER

SRI.M.SHOBHA, PRESIDENT

1. This  complainant  filed this complaint against the Opposite parties  for reliefs

1. To Direct the OP to give necessary arrangements to recover the sum of Rs.6,25,590/- which complainant has paid to the medical expenses.
2. Compensation for the mental agony of Rs.5,00,000/-.
3. and Rs.5,00,000/- for the deficiency of service, Unfair trade practice, negligence to rectify the mistake, Expenses incurred and financial losses of Rs.5,00,000/- and such other reliefs.

2.  The case of the complainant is that:

It is case of the complainant that he obtained Health insurance policy from OP-2 dt.28.10.2019 which was the renewal of the pre-existing policy issued by the OP-1. As per the invoice complainant had paid Rs.14,755/- to OP-1.

It is further case of the complainant that he has admitted to the Relive hospital situated at Bagalur, Bengaluru on 14.09.2020 and discharged on 01.10.2020. The complainant was admitted to the hospital due to the breathlessness, cough and fever. After the investigation in the above hospital, it came to know that the complainant was suffering from Covid-19 disease. After treatment about 17 days the complainant had discharged from the hospital in a stable condition. The total medical expenditure bill was Rs.6,25,590/- in the inpatient bill.

It is further case of the complainant that the complainant has approached the OP-1 for the reimbursement of the expenses incurred due to the treatment. He has produced all the documents relating to treatment, discharge summary and bills related to the diagnosis at the  Seven Hills Diagnostics Laboratory etc. But for the utter shock and surprise to the complainant, the OP-1 had repudiated the request and sent an intimation letter dt.24.11.2020. According to the said letter, it was stated that the insured was paid only Rs.50,000/- and is not aware of the final bill charged, but submitted final bill is for Rs.6,00,000/-. Further, there is no government authority license for treating Covid-19 patient in the above said hospital and also there is no lab  or pharmacy license.  Thus there is discrepancy in the records  which amounts to misrepresentation of facts. But those reply ambiguous  and intended to deprive the rights of the complainant. The intention behind this malafied in nature, there is no truth in the reply and the complainant admitted as per terms and conditions of the insurance policy provided by the OP-1.

It is further case of the complainant that the complainant waited for a longtime for the OP-1 & 2, but all that has been went in vain, left with no other alternative, the complainant  got issued legal notice though his counsel. After service of legal notice to OP-1 & 2, they have not even bothered to reply to the legal notice. The OP-4 sent reply dt.24.08.2021 stating that complaint to the office of the insurance Ombudsman has to be in prescribed format.  Accordingly, the complainant approached the OP-1 in the prescribed format advised by OP-4 briefing the facts of the grievance and explaining that the insurance claim had made by the complainant on 20.11.2020.

It is further grievance of the complainant that inspite of multiple communications with the OP to sort out the above issue, the same has not been addressed. For no fault of the complainant the OP have  harassed and penalized the complainant. As he was fed up with the poor response from the OP and the OP made serious deficiency of service and criminal breach of trust and trying to be silent  on this issue even after a written legal notice dt.24.08.2021 communication was  sent from the complainant through his counsel. The complainant is from the poor background. The Covid-19 was a hammer blow to the life of the complainant, but the complainant  believed that the insurance which made will stand for his rescue at the critical situation.  But all the faith he kept on the OP went in vain. In the absence of the fulfillment of the obligation of the OP the complainant had to undergo serious troubles to arrange the money to pay the hospital bill. The complainant’s relatives  had to  accumulate the required money by paying abnormal interest to the lenders. The interest paid by him to the lenders ruined the normal life of the complainant. The humiliation caused by the complainant  due to non-payment of the debt which arose due to the hospitalization is irreparable. With the repeated approaches to the OP, the OP have not responded. In view of the irresponsible and dishonest act the OP and the complainant decided to file the complaint. Hence,  he  filed this complaint seeking reliefs.

3. After service of notice, OPs have appeared before this commission through their counsel. OP’s have filed their version after lapse of 45 days. Hence, version of OP was taken as nil.  

4. The complainant in order to prove his complaint was examined as PW1 and relied on Ex.P1 to P13. OPs have neither adduced any evidence nor submitted arguments.  

5. We heard the arguments of the complainant.

6. 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?

7. 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

8. Point Nos.1 and 2:.Perused the complaint, affidavit evidence and documents produced by the complainant. The complainant has obtained insurance policy from the OP-2 on 28.10.2019, which was renewed  of the pre-existing policy. As per invoice the complainant has paid Rs.14,755/- to the OP-1.

9. It is further contention taken by the complainant that he was admitted to the Relive Hospital, Bengaluru on 14.09.2020 and he was discharged on 01.10.2020.  The complainant was admitted to the hospital as he was suffering from breathlessness, cough and fever. After investigation done in the above said hospital, it came to know that the complainant was suffering from Covid-19 disease. After the treatment about 17 days he was discharged from the hospital in a stable condition. The total medical expenses was Rs.6,25,590/-.
10. It is further case of the complainant that after he approached the OP-1 for reimbursement of medical expenses incurred due to treatment with the related documents obtained from the Relive hospital, the OP-1 has repudiated the claim request of the complainant stating that this complainant has paid only Rs.50,000/- and he is not aware of the final bill charged, but he submitted final bill is for Rs.6,00,000/-. Further there is no government authority  license for treating Covid-19 patient in the above said hospital and also there is no lab and pharmacy  license. There is discrepancy in the records. It amounts to misrepresentation of the facts. The complainant  has waited for a longtime. Inspite of that the OP have not settled the claim. He also got issued legal notice on 24.08.2021 and it was duly served on OP, inspite of service of notice OP-1 & 2 have not even replied to the legal notice, after that he has filed this complaint.

11. It is further grievance of the complainant that the OP have harassed and penalized the complainant and  the complainant is from poor background. He has raised loan from the financers and paid medical bills in view of the repudiation made by the OP. Even though the policy was in force, the OP have refused to pay the amount.

12. The complainant in support of his contention has produced 13 documents. Ex.P1 is the insurance policy, it clearly discloses that he has obtained policy from OP-1. It is pertinent to note here that during the pendency of the complaint as per orders of this Commission dt.22.03.2022 OP-3 & OP4 were deleted. The complainant has obtained policy from OP-2 and it was in force from 28.10.2019 to 27.10.2020. It is floater sum insured for Rs.3,00,000/- and the limit of coverage was restricted to Rs.4,65,000/- with recharge benefit of Rs.75,000/- and bonus of Rs.1,65,000/- as per Ex.P1. Ex.P2 is repudiation letter and it clearly discloses that the OP have repudiated the claim of the complainant on the ground that there is discrepancy in the records, it amounts to misrepresentation of facts. Further  there is no government authority license for the hospital, in which the complainant has taken treatment for Covid-19 and there is no lab or pharmacy license. The complainant also paid only advance amount  of Rs.50,000/- and he has not aware of the final bill charged, but submitted final bill for Rs.6,00,000/-.

13. The complainant has also produced discharge summary as Ex.P3. It clearly discloses that the complainant was admitted to the hospital on 14.09.2020 at 10.20.PM. and discharged  on 01.10.2020 at 11.00AM. He was treated for Covid-19 positive. The complainant was suffering from breathlessness, cough and fever for 02 days back at the time of admission to the hospital. The hospital authorities have treated the complainant for Covid-19 after nebulization   with oxygen. The complainant was treated in the hospital for 17 days. He also produced inpatient bills  issued by Relive hospital for a sum of Rs.63,841/-, rechargeable charges in all total bills amounts to Rs.6,25,590/-. The complainant has paid entire amount on his own. After that he has submitted the claim application to the OP for reimbursement of the amount. Ex.P5 is the diagnostic report. Ex.P6 is copy of the payment of bill dt.01.10.2020, the complainant has paid Rs.6,25,590/- to the Relive Hospital. Ex.P7 is the legal notice issued by the complainant’s counsel to the OP dt.24.08.2021. Ex.P10 is the reply issued by OP stating that the company shall not be liable to make any payment under the policy in respect of  any claim. Ex.P11 is order passed by  the Ombudsman. Ombudsman has closed the file stating the  complainant was not appeared within 45 days and they have presumed that the complaint has been resolved. On this ground they have closed the complaint.

14. It is clear from the evidence of the complainant and documents , the complainant was admitted to the Relive hospital, Bengaluru for Covid-19 treatment and he was taken treatment for 17 days and medical bills were issued by the Hospital for Rs.6,25,590/-. Even though the policy was in force, OP have not entertained the claim application and they have rejected the claim made by the complainant stating that there is discrepancy  with records, it amounts to misrepresentation.

15. It is clear from the policy that the limit restricted shown in the policy Ex.P1 was Rs.4,65,000/-, Sum insured was Rs.3,00,000/-. The policy was in force during time of  treatment taken by the complainant in the hospital. There is no exclusive clause mentioned in the policy that the treatment for Covid-19 is not at all payable.

16. The only objection raised by the OP is that the hospital is not recognized for treatment of covid-19 and the pharmacy and lab in the hospital have no license. Hence, they have repudiated the claim of the complainant.

17. It is pertinent to note here that during Covid-19 pandemic, even the government has recognized some of the hospitals  and in view of the rush to the  recognized hospitals they are unnable to admit the patients for treatment. Under this circumstance in order to save their life the patient have also admitted to the hospital, which were not treating  Covid19. Under these circumstances the complainant was admitted to the Relive hospital and he was taken treatment. When the complainant was admitted to the hospital in emergency condition, it is very difficult for him or his family members to investigate whether the said hospital was recognized by the government for treating Covid-19 patients and whether the pharmacy and lab having license for running the lab and pharmacy.

18. There is no terms and conditions in the policy that the OP will not refund the amount if the insured has taken treatment in a unrecognized  hospital and has taken  medicines  and availed tests in the pharmacy and laboratory  which was not holding license. When the life of the insured  is at the stake it is very difficult for the insured to identify about recognition issued by the Government  for treating Covid-19 patients and license obtained by pharmacy or lab for running the same. It is duty of the OP to cover the risk when the   policy was in force  and Covid-19 treatment is not at all excluded in the policy.

19. It is pertinent to note here that sum assured was Rs.3,00,000/- and limit of coverage is  Rs.4,65,000/- and recharge benefits  of Rs.75,000/-. Hence, the complainant is entitled for refund of Rs.4,65,590/-.  Even though the policy was in force, the OP would not  have repudiated the claim and in view of this the complainant and his family members have under went severe mental agony, financial loss, since the complainant is from very poor background. Even though the  OPs  have appeared before this commission failed to submit their version within 45 days. Under these circumstances, the allegations made in the complainant and documents produced by the complainant are not at all disputed or challenged by the OP. Under these circumstance, there is no reason to disbelieve the evidence and documents produced by the complainant. The repudiation made by the OP amounts to deficiency of service since, the policy was in force on the date of treatment. The complainant is also entitled for reimbursement of the medical expenses. Hence, we answer point no.1 in the affirmative and Point No.2 affirmative in part.  

20. Point no.3:-.  In view of the above discussions, the complaint is liable to be allowed in part and complainant is entitled for Rs.4,65,000/- towards medical expenses. The complainant is also entitled for compensation of Rs.1,00,000/- for the financial loss and also mental agony suffered by him and his family members. The complainant is also entitled for litigation expenses 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 Rs.4,65,000/- with interest at 10% p.a. from the date complaint towards medical expenses with compensation of Rs.1,00,000/- along with Rs.10,000/- towards litigation expenses.
3. 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.4,65,000/- will carry interest at 12% p.a. after expiry of 60 days till realization of the amount.
4. 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 15^th  day of December, 2022)

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

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