By. Smt. Beena. M, Member:-
This is a complaint filed under section 35 of the Consumer Protection Act 2019.
2. Brief facts of the case are given below: The Complainant had taken a medical insurance policy namely Arogya Plus Policy for himself and his wife Asha M.N. from the Opposite Party on 11/08/2022 covering the period from 11/08/2022 to 10/08/2023. During the subsistence of the said policy, the wife of the Complainant was admitted in Leo Hospital, Kalpetta, Wayanad on 03.01.2023, due to acute pain over left ankle. During the period of treatment, she had undergone surgery and was discharged on 07/01/2023. At the time of admission in the hospital, the Complainant had intimated the Opposite Party about the hospitalization of his wife and applied for cashless facility. But the Opposite Party repudiated the claim without any reasonable ground. Then the Complainant paid the entire bill of treatment to the hospital. Thereafter, the Complainant submitted claim application for reimbursement of Rs.73,539.96/- but the application was not processed by the Opposite Party. This act of the Opposite Party amounts to deficiency in service and it caused great inconvenience and hardship to the Complainant. Hence, this Complaint.
3. Commission issued summons for the presence of Opposite Party. Summons was served on 12/06/2023, but the Opposite Party failed to appear before the Commission as ordered in the summons on the date fixed, hence the Opposite Party was set ex-parte.
4. To prove the contentions of the Complainant, the Complainant filed chief affidavit and produced some documents. The documents produced were marked as Ext. A1 series, A2 and A3.
5. The case of the Complainant is that Opposite Party did not settle the claim without any valid reasons. The Opposite Party was informed that the claim of the policy was cashless, but the Opposite Party refused cash less policy benefit vide letter Ext A3. Ext.A1 series are the medical bills of the wife of the Complainant. It shows that the Complainant had spent an amount of Rs.69,619.86/- towards medical expenses. The wife of the Complainant was discharged from the hospital on 07/01/2023 as per discharge summary Ext A2. After discharge, claim application was lodged with Opposite Party. After similar follow ups by the Complainant, the Opposite Party had mailed the Complainant on 07.01.2023 stating that “We, regret to inform you that we are unable to extend the cashless facility for this claim due to the following reasons. The patient may continue to avail the treatment as per the treating doctor’s advice. Insured may resubmit the claim with complete set of documents. For a possible reconsideration after discharge the reimbursement of the claim will be processed subject to admissibility as per terms conditions and conclusions of the policy issued to the insured.
6. Since they have stated in the notice that the policy has been repudiated on grounds as per Ext. A3, the Opposite Party admitted that the Complainant had valid insurance policy at the time of hospitalization, as per policy No.0000000029954186/2022. The Opposite Party failed to disclose what were the medical grounds lead to repudiate claim of the Complainant. Upon considering the submissions of the Complainant and on careful scrutiny of the entire materials on records, we hold that the document submitted by the Complainant remained unchallenged testimony. The very fact that the Opposite Party remaining ex-parte leads to draw inference that Opposite Party admitting the claim of the Complainant. Despite knowledge of the facts, the Opposite Party failed to appear in the case before this Commission and also failed to rebut the contentions of the Complainant itself shows the negligent attitude of the Opposite Party.
7. So, in view of the above discussion, we are of the view that the repudiation of claim of the Complainant in this case is not justified. Rejection of claim without any reasonable ground amounts to deficiency in service on the part of the Opposite Party. Ext.A1 is the only record to show the expenditure of the treatment. As per Ext. A1, the Complainant has incurred an amount of Rs.69,620/- only for treatment. Though the Complainant claimed Rs.73,539/- for settling the bill, no documents have been produced for the balance amount. Hence, he is entitled for Rs.69,620/- only as claim from the Opposite Party.
8. Since the cashless facility was denied by the Opposite Party, he has suffered much hardship and inconvenience for which we order a sum of Rs20,000/- as compensation also, which has to be paid by the Opposite Party along with a sum of Rs.8,000/- as cost.
In the result the Complaint is partly allowed directing the Opposite Party to pay a sum of Rs.69,620/- (Rupees Sixty Nine Thousand Six Hundred and Twenty Only) as insurance claim, to pay Rs.20,000/- (Rupees Twenty Thousand Only) towards compensation along with Rs.8,000/- (Rupees Eight Thousand Only) as cost to the Complainant within 30 days of receipt of this order. If the Opposite Party fails to comply with the order, another 9% interest will be payable on the total amount calculated with interest.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 12th day of September 2023.
Date of Filing:-27.05.2023
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
APPENDIX.
Witness for the Complainant:-
PW1. O. A. Subramanian. Business.
Witness for the Opposite Party:-
Nil.
Exhibits for the Complainant:-
A1(Series). Bills ( 8 Numbers).
A2. Copy of Discharge Summary. Dt:07.01.2023.
A3. Copy of Repudiation of Cashless facility. Dt:07.01.2023.
Exhibits for the Opposite Party:-
Nil.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR
CDRC, WAYANAD.
Kv/-
