ORDER

BY SRI.H.R.SRINIVAS, PRESIDENT.

This is the Complaint filed by the Complainant U/S Section 12 of Consumer Protection Act 1986, against the Opposite Party (herein referred in short as O.P) alleging the deficiency in service in not reimbursing the full amount of medical expenses incurred towards his wife’s treatment and for refund of the same along with damages of Rs.50,000/- and litigation expenses and for other reliefs as the Commission deems fit.

2.      The brief facts of the complaint are that;

The complainant is a director of Sri.Anjaneya Co-operative Bank, having its office at No.38, Sri Sri Balagangadharanatha Swamiji Road, Malleshwaram, Bangalore.  The bank has obtained health policy bearing No.10839796 from OP for the benefit of its employees, Directors and dependents.  The said policy was for a period of 20.10.2016 to 19.10.2017.  

3.      It is contended that the wife of the complainant Smt. Pushpa, age 52 years, was having pain in the epi-gastric region and consulted doctor at Columbia Asia Hospital, Malleshwaram, and diagnosed as having “Acute Choli Syseitis” and advised to undergo surgery and she underwent surgery and an amount of Rs.1,08,979/- was paid to the hospital. The same was claimed through TPA of OP1.  OPs have reimbursed only Rs.20,000/- against the claim of Rs.1,08,979/-.  They are due Rs.88,979/- towards the reimbursement of the hospital charges.  OPs are bound to pay the entire amount of the hospital expenses. Since they have denied the payment of the entire amount of expenses incurred complainant issued a legal notice on 06.10.2018 demanding OPs to pay the balance of amount for which OP 1 refused to receive the same and afterwards has sent an untenable reply refusing to pay the amount.  Since it is a group health insurance policy, covers the risk of members of the insurance policy, OP is liable to reimburse the expenses incurred for the treatment of his wife.  The cause of action for the complainant arose on 20.04.2018 when the OP failed to pay the amount and Hence the complaint.  

4.      Upon the service of notice, OP 1, 2 and 3 appeared before the Commission through their advocate and filed the version contending that the complaint is not maintainable either in law or on facts and liable to be dismissed as the same is filed with malafide intention, and on baseless grounds.  There is no negligence or deficiency in service on the part of OPs.  The policy of medical insurance is issued subject to the terms and conditions and exclusions and exceptions mentioned in the insurance policy.  It has admitted issuing of policy to Anjaneya Co-operative Bank, under group care policy, covering for the period 21.10.2017 to 20.10.2018 and also admitted the claim made by the complainant in respect of his spouse for “acute colio systies” and undergoing surgical treatment of removing the gallbladder and also the claim amount. 

5.      It has further contended that as per the policy certificate issued, the liability of the OP is restricted to Rs.20,000/- for any treatment pertaining to the cataract, appendix, Arnea, Piles, gallbladder and hydrocele.  As per the conditions mentioned in the insurance certificate it deducted a sum of Rs.88,976/- as they are non-payable items proportionate charges and nonmedical expenses.  It has deducted an amount of Rs.13,353/- under the head of consumption which are permanently excluded under clause 3.2 and the remaining amount on nonpayable items and proportionate deductions under clause 2(2.3)(a) of the policy terms and conditions.  In view of the same denying all the allegations made against it, has contended and prayed to dismiss the complaint.

6.      In order to prove the case, both the parties filed their affidavit evidence and produced documents. Arguments Heard. The following points arise for our consideration:-

1) Whether the complainant has proved deficiency in service on the part of the Opposite Parties?

2) Whether the complainant is entitled to the relief prayed for in the complaint?

7.     Our answers to the above points are:-

POINT NO.1:            In the Affirmative

POINT NO.2:            Partly in the affirmative.

                                For the following.

REASONS

8.     POINT No.1:-

   Perused the complaint, version, affidavit evidence and the documents produced by respective parties.  It is admitted fact by OP that the complainant as a Director of Sri.Anjaneya Co-operative Bank, and his family members are covered under the insurance policy mentioned in the complaint and further the claim made by the complainant in respect of Acute Choli Syseitis and after the surgery for a sum of Rs.1,08,979/-.

        9.     It is the specific contention of the complainant that the entire amount spent by him for the surgery in the hospital towards his spouse Smt. Pushpa is to be paid by the OP as they are covered under the policy and the terms and conditions are very specific for reimbursement for the hospital claims.  Ex.P1 to P5 have been produced, which clearly goes to show that the wife of the complainant underwent surgery for Acute Choli Syseitis and the complainant made a payment of Rs.1,08,979/- and after the claim made, he was only given Rs.20,000/- whereas his claim is for the total amount.  The act of OP in not paying the entire amount, amounts to deficiency in service and violation of the terms and conditions of the policy amounting to unfair trade.

        10.   On the other hand, it is the specific case of OP that though the complainant has obtained the insurance and made claim for Rs.1,08,979/-, as per the terms and conditions of the policy, they are only liable to pay Rs.20,000/- against the claim of Rs.1,08,979/-, under the guise that the said amount of Rs.20,000/- for gallbladder (Acute Choli Syseitis) is fixed and the remaining amount for which the complainant is claiming is not admissible because they are excluded permanently under clause 3.2 r/w annexure C of the policy terms and conditions and also deductions made under non payable items as per clause 2(2.3a) of the policy terms and conditions.  It has also produced the terms and conditions of the policy.

        11.   OP has referred to clause 2(2.3a) of the insurance wherein, it is very specific that it is only

(a) If the insured Member is admitted in a Hospital room where the Room rent incurred is higher than the eligible limit, as specified below then the insured Member shall bear the ratable proportion of the medical expenses (including surcharge or taxes thereon) as specified in the policy certificate in the proportion of the Room Rent actually incurred less room rent limit and divided by room rent actually incurred provided that we have admitted a claim under clause 2.1(a)”

and 3.2 regarding permanent exclusions wherein upon going through the same there is no mention of exclusion of any of the items.  Whereas, in annexure C certain items mentioned therein from Point No.1 to 199 have been excluded, which includes non-medical expenses in the hospital, such as toiletries, cosmetics, personal comforts or convenience items which includes administration and registration charges and others and list of expenses generally excluded, such as bandages, surgical blades, aprons and luxury taxes, housekeeping charges, alcohol swabs, issuing of birth certificates, washing charges and other facilities provided. 

12.   Whereas in the repudiation of the claim the OP has just paid Rs.20,000/- and as per annexure 2 the reasons for deduction mentioned as non-payable items and also remarks made is that gallbladder surgery restricted to Rs.20,000/- only and hence it has paid Rs.20,000/- to the account of the complainant.  It has denied the profession fee charges in respect of the surgery of charges and only given proportionate charges.  It is not made clear as to what is the proportionate charges for each and every item and also summarily it has taken the decision that for gallbladder surgery Rs.20,000/- is the maximum payable(restricted to Rs.20,000/-).  Nowhere the same has been brought to the notice of the complainant or to the knowledge of the Directors of Sri.Anjaneya Co-operative Bank, who have purchased the insurance policy from OP for its employees amounting to 34 persons and 66 dependents in all for 100 members, by collecting a premium amount of Rs.3,20,000/- including the SGST and CGST.  In view of the non-disclosing of the correct amount payable for each and every surgery and deducting from the claim amount as exclusions, amounts to deficiency in service and also unfair trade.

        13.   As per the said annexure C the OP is entitled to deduct the hospital consumables only, whereas it has to pay the operation theatre charges in full and other surgical charges and other hospital charges, excluding the consumables, diet and toiletries.  Hence deducting a sum of Rs.88,979/- out of the claim of Rs.1,08,979/- in our view amounts to deficiency in service and unfair trade.  Hence we answer Point No.1 in the affirmative and direct OP to pay the remaining amount after deducting only the consumables toiletries, diets given to the patient during the hospitalization period other items only as mentioned in annexure C of the insurance policy within 30 days from the date of receipt of this order and also to pay Rs.10,000/- towards damages for causing mental agony and physical strain and Rs.5,000/- towards expenses.  Hence we answer point No.2 partly in the affirmative and pass the following;

ORDER

1. Complaint is allowed in part with cost.
2. OP is directed to pay the amount after deducting the exclusion portion mentioned in schedule C of the insurance policy towards the registration fee, admission fee, toiletries, diets, hospital consumable items only and to file the report to this Commission to that effect, and also to pay interest at 12% p.a., on the said payable amount to the complainant from the date of claim.
3. OP is also directed to pay Rs.10,000/- towards damages for causing mental trouma and agony and further Rs.5,000/- towards litigation expenses.
4. The OP is further directed comply the above order within 30 days from the date of receipt of this order and submit the compliance report to this forum within 15 days thereafter.
5. Send a copy of this order to both parties free of cost.

Note:You are hereby directed to take back the extra copies of the Complaints/version, documents and records filed by you within one month from the date of receipt of this order.

(Dictated to the Stenographer over the computer, typed by him, corrected and then pronounced by us in the Open Forum on this 11^th day of November 2020)

MEMBER                                PRESIDENT

ANNEXURES

1. Witness examined on behalf of the Complainant/s by way of affidavit:

Copies of Documents produced on behalf of Complainant/s:

Ex P1: Copy of the Insurance Policy

Ex P2: Copy of the Discharge summary

Ex. P3: Hospital bills

Ex P4: Copy of the legal notice

Ex P5: Copy of the reply.

2. Witness examined on behalf of the Opposite party/s by way of affidavit:

RW-1: Sri.Prakhyath V.S. - OP

Copies of Documents produced on behalf of Opposite Party/s

Ex R1: Copy of the Authorization letter.

Ex R2: Insurance policy certificate

Ex R3: Terms and conditions

Ex R4: Claim Form

Ex R5: Claim approval and settlement details

Ex R6: Claim denial letter

MEMBER                                PRESIDENT