ORDER

SRI.H.R. SRINIVAS, PRESIDENT

1.      This is the complaint filed by the complainant against the Opposite Party (herein referred to as OP) under Section 35 of the Consumer Protection Act, 2019 for the deficiency of service in not honouring the insurance claim in respect of reimbursement of hospitalization charges even though the medical insurance issued by OP was in force and for reimbursement of the same and for damages towards sufferance caused by OP along with interest at 12% per annum from 10.08.2020 and also legal expenses and for cost and other reliefs as the commission deems fit.

2.      The brief facts of the complaint are: that the complainant had obtained a health insurance from OP for the period 26.04.2018 to 25.04.2018 to cover the medical expenses in the event of disease, accident or unfortunate incident. On 07.02.2019 when he was standing in the main road near Dommaluru Flyover, Bangalore, a tempo traveller came in a rash and negligent manner and dashed to him and thereby he suffered injuries to his legs, head and body and taken to Prashanth Hospital in Bommanahalli for treatment and he took treatment till 09.02.2019 and thereafter shifted Hamilton Bailey Hospital, HSR Layout and there he took treatment till 16.02.2019 and he was discharged. He incurred medical expenses for his treatment to an extent of Rs.1,18,000/-. He also underwent physiotherapy sessions, and made a claim with OP for reimbursement of the said amount.

3.      As per the terms and conditions of the policy issued, Hospitalization expenses incurred as inpatient during the policy period, pre-hospitalization medical expenses incurred 30 days prior to hospitalization, and post hospitalization medical expenses incurred within 60 days from the date of discharge from the hospital is covered in the insurance policy.  Inspite of the same, the claim made in that respect was did not reimbursed,  and thereby he was put to physical and mental agony. There is deficiency in service and unfair trade practice on the part of OP. He had to issue legal notice demanding reimbursement of the hospitalization charges, whereas, though received, OP did not respond and complied. Hence the complaint.

4.      Upon the service of notice, OP appeared before the commission and filed version contending that the complaint is not maintainable either in law or on facts.  The complainant has suppressed the material facts and misrepresented the same. Complainant did not furnish all the medical records when called for after the claim is made. Hence they had to close the claim case of the complainant as “no” claim made.  They made several attempts with the complainant to provide the medical records, discharge summary, FIR in respect of the accident. Inspite of it, complainant did not coordinate with and supported the OP in providing the medical documents. Initially he only submitted a few documents, whereas, when requested to provide the further details, complainant did not provide the same. To assess the eligibility of the claim, the X-ray report, FIR, discharge summary and all relevant hospital document and original bills are required.

4.      He was intimated on 19.04.2019 to provide the said documents, He was also intimated on 21.05.2019 again to produce the documents and the complainant did not provide the same. Hence they had to close the claim of the complainant as “no claim” on 21.08.2019.  In view of this, there is no deficiency in service or willful negligence on its part. There is no unfair trade practice and prayed the commission to dismiss the complaint.

5.     In order to prove the case, both parties have 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 party?

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

6.     Our answers to the above points are:-

POINT NO 1: In the Affirmative

POINT NO 2 : Partly in the affirmative

                      For the following.

REASONS

POINT NO 1:

7.      Upon perusing the complaint, version, affidavit evidence, documentary evidence, it becomes clear that complainant obtained medical insurance policy for Rs.3,00,000/- commencing from 26.04.2018 to 25.04.2019. It is not in dispute that the complainant met with an accident and hospitalized and took treatment as an inpatient firstly in the Prashanth Hospital and later Hamilton Bailey hospital from 07.02.2019 till 09.02.2019  and 09.02.2019 to 16.02.2019 respectively.  Complainant has produced all the medical documents pertaining to the treatment before this commission along with discharge summary, lab reports and medical bills.

8.      It is the specific contention of OP that, after making a claim, only some of the medical documents were produced whereas complainant failed to produce original records in respect the entire claim. In the document filed by OP, it has sought for original paid receipt in respect of both hospitals, report in respect of fracture and discharge summary and receipt for Rs.66,000/- with Hamilton Bailey Hospital, X-ray report supporting fracture. Only receipt for Rs.25,350/- was submitted whereas, the receipt for remaining amount has not been submitted.  OP has written letters and reminder to the complainant to produce the said documents. It is also mentioned that, inspite of several reminders and requests to provide the medical documents, the same has not been produced and they are closing the claim as “no claim” in their records. That is the reason  the complainant has come up before this commission.

9.      It is to be noted here that, the complainant has produced all the relevant documents to this commission along with the complaint. The copy of the same has been made over to the OP for filing its objection/version.

10.    Even if the allegation of OP that, all the documents have not been furnished to them, when OP requested repeatedly, when all the documents pertaining to the treatment of the complainant as filed before this Commission when furnished to OP, OP ought to have considered the same and ought to have reopen the claim of the complainant and ought to have reimbursed the amount to which the complainant was entitle to in accordance with the terms and conditions of the insurance policy. In view of not acting inspite of getting all the documents from this commission and not settling the claim of the complainant amounts to deficiency in service. Hence we answer POINT NO.1 IN THE AFFIRMATIVE.

POINT NO.2:

11.    In the result as per the documents filed by the complainant, the complainant has produced the receipts, bills and payments towards the hospitalization charges to the extent of Rs.1,18,000/- and also claimed the said amount along with interest at 18% per annum.  When we have held that, OP services is deficient, OP is bound to reimburse the medical expenses and charges incurred by him.  Hence we direct OP to pay a sum of Rs.1,18,000/- to the complainant along with interest at 12% per annum  from the date of accident i.e. on 07.02.2019 till the payment of the entire amount and further a sum of Rs.25,000/- towards  damages and Rs.10,000/- towards litigation expenses. In view of this, we answer POINT NO.2 PARTLY IN THE AFFIRMATIVE and pass the following:-

ORDER

1. The complaint is partly allowed with cost.

2. OP i.e. ROYAL SUNDARAM GENERAL  INSURANCE CO. LIMITED, Represented by its Authorised Signatory is hereby directed to pay a sum of Rs.1,18,000/- to the complainant along with interest at 12% per annum  from the date of accident i.e. on 07.02.2019 till the payment of the entire amount.

3.   Further OP to pay a sum of Rs.25,000/- towards damages and Rs.10,000/- towards the litigation expenses to the complainant..

4. OP is hereby directed to comply the above order within 30 days from the date of receipt of this order and submit the compliance report to this Commission 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 Commission on this day the 21^st day of February 2022)

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 legal Notice

Ex P2: Postal receipt

Ex P3: Online copies

Ex P4: Copy of the Health Insurance Policy.

Ex P5: Copies of Medical expenditure bills.

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

RW-1: Sri Sudhakar.H, State Head –Leal & TP/authorized signatory of OP

Copies of Documents produced on behalf of Opposite Party/s

• Nil-

MEMBER                  PRESIDENT

RAK*