By. Sri. A. S. Subhagan, Member:-

            This is a complaint filed under section 35 of the Consumer Protection Act 2019.

            2.  Facts of the case in brief:-  The Opposite Party had issued a Senior Citizens Red Carpet Health Insurance Policy  No.P/181218/01/2022/006616 covering the period from 13.12.2021 to 12.120.2022 the sum insured was Rs.4,00,000/-.  The proposer of the policy was Smt. Tessy. P. T, Kalayil House, Bhoodanam Colony Post, Pulpally, Wayanad as per the proposal dated 12.12.2021.  As per the policy terms and conditions, the Opposite Party is liable to pay sum of Rs.4,000/- per day towards room rent, Rs.8,000/- per day towards ICU charge, 25% of the doctors fee, 50% of sum insured towards anaesthesia, blood, oxygen, operation theatre charge, surgical appliance, medicine, drugs, diagnosis, materials and x-ray, dialysis etc for Cardio vascular disease Rs.2,25,000/-, all other major surgeries Rs.2,00,000/- 50% for the claim arising out of pre-existing disease.  On 05/12/2022 the Complainant was admitted in the Baby Memorial Hospital, Kozhikode for the treatment “Sick Sinus Syndrome with Sinus pauses up to 3.2 seconds, Mild Coronary Artery Disease”, Permanent pace maker implantation (DDDR MRI Conditional) made on 06/12/2022, the petition was discharged on 09/12/2022.  The Complainant had paid sum of Rs.2,69,516/- towards treatment expense.  The Complainant submitted the claim before the Opposite Party but the Opposite Party did not satisfy the claim so far.  Instead of that the Opposite Party sent letters demanding the additional documents/information ie letter from the treating doctor stating exact duration of Sick Sinus Syndrome, CKD how and when diagnosed “Hence the Complainant submitted a certificate form the treating doctor to the Opposite Party.  As per the Certificate the treating doctor specifically stated that “this is to certify that Mr. Thomas. P. P was diagnosed as Sick Sinus Syndrome and CKD on presentation to him on 29/10/2022”.  The Complainant had submitted the claim before the Opposite Party only for the treatment of Sick Sinus Syndrome not for the CKD.  But the Opposite Party had repudiated the claim for the reason that “Non submission of required documents:- In order to process the claim, we had requested you vide letter dated 03/01/2013 to furnish letter from the treating doctor the exact duration of CKD (Kidney Disease), how and when was first diagnosed, past consultation details, investigation details, investigation reports and complete treatment records related to CKD.  We note that you have not furnished the required documents and details.  In the absence of the above documents/details, As per Condition No.5(2) of the above policy the insured person has to submit all required documents and details called for by us.  We are not able to further process your claim.  We are therefore unable to settle your claims under the above policy and we hereby repudiate your claim”.  In this case the Complainant has not made any claim with Opposite Party for CKD but for the treatment of Sick Sinus Syndrome. This Complainant had submitted the Certificate from the treating doctor dated 28/01/2023.  But the Opposite Party did not considered this Certificate.  The Opposite Party repudiated the claim illegally and without any basis.  The repudiation of the claim of the Complainant by the Opposite Party amounts to the deficiency of service and unfair trade practice.  Hence the Complainant is entitled to get entire treatment expense for Sick Sinus Syndrome sum of Rs.2,69,516/-.  Due to the deficiency of service and unfair trade practice of the Opposite Party, the Complainant sustained mental agony for that the Complainant claims Rs.2,00,000/- towards compensation for mental agony.  Therefore prayed the Commission to direct the Opposite Party to:-

1. Pay entire claim amount Rs.2,69,516/- with 12% interest from 25/02/2023 ie the date of repudiation of the claim.
2. Pay sum of Rs.2,00,000/- towards compensation.
3. Rs.15,000/- towards cost of this proceedings
4. Any other relief as deems fit and proper for the just and proper disposal of this case etc.

            3.  The Opposite Party on getting summons, appeared before the Commission and filed version.  The contents of version is as follows:-  The daughter of the Complainant had taken a Senior Citizen Red Carpet policy from the Opposite Party in the name of the Complainant on 13/12/2021 and the same had been renewed up to 12/12/2022 for a sum insured of Rs.4,00,000/- vide Policy No.P/181318/01/2022/006616.

4.  At the time of availing the policy, the Complainant was supplied with the Terms and Conditions of the policy. The terms and conditions of the Policy were explained to the Complainant at the time of proposing policy and the same was served to them along with the policy schedule.

5.  Moreover it is clearly stated in the policy schedule that “THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED”.  It is submitted that during the aforesaid policy period, the Complainant was admitted at Baby Memorial Hospital on 05/12/2022 and was diagnosed with Sick Sinus Syndrome with Sinus pauses up to 3.2. seconds, Mild Coronary Artery Disease, S P Permanent Pacemaker implantation, Normal LV Systolic function, Systematic Hypertension, Asthmatic Hypertension, Asthmatic Bronchitis, Chronic Kidney Disease. After treatment he was discharged on 09/12/2022. Thereafter the Complainant had submitted claim form with discharge summary, bills and reports for the reimbursement of the medical expenses.  In order to process the claim, the Company had issued a query letter dated 03/01/2023 to the Complainant directing to submit the following documents:-

1. Letter from treating doctor stating the exact duration of Sick sinus syndrome, CKD (Kidney Disease), how and when was first diagnosed.
2. Past consultation details, investigation reports and complete treatment records related to CKD, sick sinus syndrome
3. Past ECG, ECHO, USG report, serum creatinine report.
4. Complete sets of Inpatient case sheet records and vital charts with all days of admission

6.  As  reply to the said query letter, the Complainant had only submitted letter from treating doctor and present treatment records. But the Complainant has not furnished the Letter from treating doctor stating the exact duration of CKD (Kidney Disease), how and when was first diagnosed, Past consultation details, investigation reports and complete treatment records related to CKD. Without the required documents sought for, the Opposite Party is not able to decide the admissibility of the claim. As per Condition No:5 (2) of the policy, The Policyholder or Insured Person shall furnish such information as the Company may require for settlement of any claim under the Policy, within reasonable time limit and within the time limit specified in the Policy. Hence the Opposite Party had repudiated the claim vide letter dated 25/02/2023. As per the terms and conditions of the insurance policy, the insurance company has got every right to demand the production of necessary documents from the insured in order to process the claim. It is only due to the refusal of the Complainant to submit the required documents, in spite of the repeated requests made by the Opposite Party, that the claim submitted by the Complainant was repudiated.  As per the discharge summary, the Complainant is a known case of Hypertension, asthmatic bronchitis, Chronic Kidney Disease. But the Complainant has not submitted those details sought for by the Opposite Party. It is submitted that the treating doctor had issued the certificate after colluding with the Complainant in order to obtain the claim illegally. Without submitting those documents the Complainant is trying to mislead this Hon’ble Commission by making false allegation against the Opposite Party. There has been no deficiency of service or unfair trade practice from the part of the Opposite Party. The Opposite Party had only acted as per the terms and conditions of the policy. The Opposite Party will approve the claim only after receipt of the sufficient documents. There is liability from the side of the Complainant to submit the required documents in order to process the claim. Here in the instant case, the Complainant had violated policy condition and violation of the same will result in repudiation of the claim on the ground of non-submission of records.  The Complainant is not entitled to any of the reliefs as sought for in the complaint.  The Complainant has filed this complaint vexatiously and frivolously for the sole purpose of harassing the Opposite Party with the intention for getting unlawful enrichment from the Opposite Party who are dealing with public money and functioning under the guidelines of IRDA controlled by the Government of India. As public money is held in trust, the Opposite Party must exercise abundant caution in dealing with the claims by applying all conditions correctly.  Hence the Opposite Party prays to dismiss the complaint with cost and compensation to the Opposite Party.

7.  Chief affidavit was filed by the Complainant and the documents produced by him were marked as Ext.A1 to A8 and Ext.X1 series.  The Complainant was examined as PW1 on 20.11.2023.  One Balu. M, Deputy Manager Legal filed chief affidavit on behalf of the Opposite Party and the documents produced by  the Opposite Party were marked as Ext.B1 to B5.  He was examined as OPW1 on 03.02.2024.  Finally both parties were heard on 23.09.2024.

8.  Considering the facts and circumstances of the complaint and the evidences adduced by the parties concerned, Commission raised the following points for deciding the case.

1. Whether there has been any deficiency in service/unfair trade practice from the side of the Opposite Party?
2. If so, the relief and its quantum…?

9.  Point No.1:-  The Complainant states that he had a senior citizen’s Red Carpet Health Insurance Policy with the Opposite Party for the period from 13.12.2021 to 12.12.2022 for Rs.4,00,000/- and the proposer of the policy was one Tessy. P. T, which is not objected by the Opposite Party.  The main allegation of the Complainant is that he had submitted claim application before the Opposite Party for reimbursement of hospital expenses amounting to Rs.2,69,516/- for being treated in Baby Memorial Hospital, Kozhikode in respect of “Sick Sinus Syndrome with sinus pauses upto 3.2 seconds, Mild Coronary Artery”, but the Opposite Party repudiated the claim application of the Complainant, which is deficiency in service and unfair trade practice.  But the Opposite Party contented that the claim of the Complainant was repudiated due to non-production of certain documents such as letter from treating doctor stating that exact duration of Sick Sinus Syndrome, CKD (Chronic Kidney Disease), how and when was first diagnosed; Past Consultation details, investigation reports and complete treatment records related to CKD, Sick Sinus Syndrome, Past ECG, ECHO, USG Report, Serum creatinine reports and complete sets of inpatient case sheet records and vital charts with all days of admission etc.

10.  The Complainant states that he was treated for Sick Sinus Syndrome with sinus pauses up to 3.2 seconds, Mild Coronary Artery Decease and not for Chronic Kidney Disease.  So he submitted a certificate of the treating doctor who specifically stated that “This is to certify that Mr. Thomas. P. P. was diagnosed as Sick Sinus Syndrome and CKD on presentation to him on 29.10.2022” (Ext.A6).  On Ext.A3 which is the Discharge Summary issued from the treated hospital.  The clinical history of the Complainant stated that “73 year old male known case of systemic hypertension, asthmatic bronchitis, CKD, presented with history of dsypnoea on exertion since 2-3 months for which the consulted Cardiology OPD where ECG showed intermittent junctional rhythm, Echo shows no RWWA, normal LV systolic function, moderate PAH, TMI achieved 66% THIR at 7.5 METS.  He was then advised Holter monitoring, which showed sinus bradycardia with sinus pauses upto 3.2 seconds and advised coronary angiography followed by permanent pacemaker implantation (DDDR), now admitted for the same”.  From this clinical history itself it is clear that the patient (Complainant had the above disease since 2-3 months only).  It is admitted by the Opposite Party and is evident that the commencement of the policy period was 13/12/2021.  The discharge summary shows that it was issued on 09/12/2022 in which it is stated that the diseases started since 2-3 months.  So it is evident from the above records that the diseases and treatment occurred only after taking the policy.  So the diseases shall not come under “pre-existing diseases”.

11.  Another contention of the Opposite Party in version is that “the treating doctor had issued the Certificate after colluding with the Complainant in order to obtain the claim illegally”.  If the Opposite Party had this considered view, the Opposite Party had to examine the treated doctor in the Court.  This has not been done.  Hence the contention of the Opposite Party that the treating doctor had issued the Certificate after colluding with the Complainant is baseless and cannot be accepted.

12.  Moreover, the discussion part of the Discharge Certificate of Ext.B2 shows that 73 year old male, known case of systemic hypertension, asthmatic bronchitis, CKD was admitted for Coronary angiography followed by permanent pace maker inplantation.  Nowhere in the discharge certificate shows noted that the patient was treated for other diseases. In addition, in oral examination, OPW1 has deposed that “claim D¶bn¨n«pffXv heart disease \v th­nbpff treatment \v BWv”. AXn\v ap³]v At±l¯n\v cardiac complaint DffXmbn«v tcJsbm¶pw In«nbn«nÃ.  ]cmXn¡mct\mSv I¼\n Bhniys¸«n«pff Treatment sN¿p¶ tUmIvStdmSv certificate Bhiys¸«psIm­pff letter lmPcm¡nbn«p­v.  Kidney disease Dw Bbn _Ôs¸«v bmsXmcp claim Dw D¶bn¨n«nÔ.  This deposition also reveals that the Complainant has the right to get his claim amount.  Other contentions of the Opposite Party are seen irrelevant as to the facts, circumstances and evidences of the case.  The Complainant has stated that he has produced all the documents to the Opposite Party.

13.  So Commission finds that there is no need to produce any other document by the Complainant for processing the claim application of the Complainant.  If additional documents or clarifications were needed, the Opposite Party had to take steps and to seek such records, documents clarifications from the treated hospital.  On the contrary, the Opposite Party had repudiated the claim of the Complainant on unsustainable grounds.  This act of the Opposite Party is deficiency in service and unfair trade practice.  So Point No.1 is proved against the Opposite Party.

14.  Point No.2:- It is seen that there has been deficiency in service/unfair trade practice from the side of the Opposite Party. Therefore, the Opposite Party is liable to pay insurance claim amount together with interest, compensation and cost of the complaint.

In the result, the complaint is partly allowed and the Opposite Party is directed to

1. Pay Rs.2,69,516/- (Rupees Two Lakh Sixty Nine Thousand Five Hundred and Sixteen Only) with interest @ 8% per annum from the date of repudiation of the claim.
2. Pay Rs.40,000/- (Rupees Forty Thousand Only) towards compensation and
3. Pay Rs.8,000/- (Rupees Eight Thousand Only) as cost of this complaint.

The above amounts shall be paid by the Opposite Party to the Complainant within one month from the date of this Order, failing which the above amounts will carry interest @ 8% per annum from the date of this Order till payment.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 18^th day of October 2024.

Date of Filing:- 08.05.2023.

PRESIDENT   : Sd/-

MEMBER       : Sd/-

MEMBER       : Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              P. P. Thomas.                                  Agriculture.

Witness for the Opposite Party:-

OPW1.          Balu. M.                                            Deputy Manager, Legal.

Exhibits for the Complainant:

A1.                  Senior Citizens Red Carpet Health Insurance Policy Schedule.

A2.                  Insurance Premium Receipt.                   Dt:13.12.2021.

A3.                  Copy of Discharge Summary.                 Dt:09.12.2022.

A4.                  Copy of Letter.                                            Dt:03.01.2023.

A5.                  Copy of Letter.                                            Dt:30.01.2023.

A6.                  Copy of Certificate.                                    Dt:28.01.2023.

A7.                  Copy of Claim Repudiation Letter.        Dt:25.02.2023.

A8.                  Copy of Medical Bills.

Exhibits for the Opposite Party:-

B1.                  Copy of Policy Schedule and conditions.

B2.                  Copy of Discharge Summary.                 Dt:09.12.2022.

B3.                  Letter.                                                            Dt:03.01.2023.

B4.                  Copy of Certificate.                                    Dt:28.01.2023.

B5.                  Claim Repudiation Letter.                        Dt:25.02.2023.

X1(Series).    Original discharge summary, Original inpatient Bills, all other

original bills and original lab reports produced by the Opposite

Party.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

/True Copy/

Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-