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:- The Complainant was a policy holder of the Opposite Party Company with Policy No.P/18315/01/2022/002597 and had used to remit the policy amount properly. In the meantime Complainant’s father was confirmed Covid-19 on 21.01.2022 and from IQRA Hospital, Bathery, he was referred to DM WIMS Hospital, Meppadi. The patient was aged 65 years and considering his health condition he was admitted by the Doctors in WIMS on 21.01.2022 and was discharged on 24.01.2022. On admission, the details regarding the cashless claim policy were informed to the Hospital Authorities. When the Complainant’s father was discharged from the Hospital, not allowing cashless facility to the Complainant, the Opposite Party committed deficiency in service and as a consequence the Complainant had to make payment of Rs.25,729/- in the hospital. Then, as per the instruction from the officials of the Opposite Party Company, claim application was submitted for reimbursement to the Opposite Party but they repudiated the claim on 07.04.2022 stating that for Covid-19 patients, hospitalization was not needed but only home quarantine was required. The Complainant’s father was admitted in hospital owing to severe difficulties and for health safety precautions and as per the advice of the hospital doctor. Hence, the act of the Opposite Party Company in repudiating the claim is deficiency in service and therefore, this complaint with the following prayers
- To direct the Opposite Party to reimburse an amount of Rs.25,729/- being the hospital bill amount
- To direct the Opposite Party to pay Rs.15,000/- towards compensation and
- To direct the Opposite Party to pay Rs.10,000/- towards cost of this complaint
3. The Opposite Party appeared and filed version stating the following
It is submitted that the Complainant had taken an Arogya Sanjeevani Policy from the company’s branch office situated at Sulthan Bathery in the name of his parents, Mr.George.N.P and Mrs. Sosamma George for the period commencing from 29.07.2021 to 28.07.2022 for a sum insured of Rs.5,00,000/- vide Policy No. P/181315/01/2022/002597. 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 the Complainant along with the Policy Schedule. It is submitted that during the aforesaid policy period, the Opposite Party received a request for cashless hospitalization from DM WIMS Hospital, Wayanad stating that the Complainant’s father, Mr. George. N.P was admitted at the hospital on 21.01.2022 and was provisionally diagnosed with Covid-19. After receipt of the same, the Opposite Party had issued a query letter dated 22.01.2022 to the hospital to forward the following documents:-
- Letter from the treating doctor with seal and signature stating the need for IP care.
- SP02 Chart.
Based on the query letter, the hospital had forwarded the treatment records and the discharge summary pertaining to the patient. In the discharge summary, the diagnosis is mentioned as Covid-19 and COPD (Chronic Obstructive Pulmonary Disease). But the hospital has not forwarded the copy of first consultation when COPD was diagnosed with exact duration and letter from treating doctor with seal and signature stating the exact duration of COPD. Hence the Opposite Party had denied the preauthorization request for cashless treatment and informed the Complainant and the hospital, vide letter dated 24.01.2022. After treatment, the insured patient was discharged on 24.01.2022 and thereafter, the Complainant had submitted claim form with discharge summary, bills of Rs.25,729/- and reports for the reimbursement of the hospital expenses. It is submitted that in the discharge summary issued by DM WIMS Hospital, Wayanad, the clinical parameters and the vitals were mentioned as follows:-
- PR (Pulse rate): 76bpm (Normal Range: 60 -100 beats per minute).
- BP (Blood pressure): 190/100 mm Hg.
- RR (Respiration rate):- 25/MIN
- SP02: 95% in RA (Normal Range: 94% to 100%)
It is submitted that as per the discharge summary, the clinical parameters and vitals were normal. The treatment records from the hospital noted the vitals as following:-
21.01.2022
- BP (Blood Pressure): 110/70
- PR (Pulse rate): 74 (Normal Range: 60 -100 beats per minute).
- RR (Respiration rate): 20
- SP02:- 97 % (Normal Range: 94% to 100%)
22.01.2022
- HR (Heart Rate):- 62 bpm
- RR(Respiratory Rate:- 20
- BP (Blood Pressure):-110/70 mm Hg.
- SPO2:- 96% (Normal Range:94% to 100%)
It is submitted that as per the discharge summary and the case sheet, the Complainant’s vitals were stable & minor symptoms were only noted. Here Covid positive had been diagnosed but the patient's vitals were stable, Respiration rates, SP02, Pulse rate seems normal, temperature not mentioned, hospitalization was not warranted and he was under observation. SP02 is oxygen saturation, is a measure of the amount of oxygen-carrying hemoglobin in the blood relative to the amount of hemoglobin not carrying oxygen. The body needs certain level of oxygen in the blood or it will not function as efficiently. In fact, very low levels of SP02 can result in very serious respiratory symptoms. The normal oxygen level which is measured by a pulse oximeter usually range from 95% to 100%. The Blood oxygen levels below 90% are considered low (hypoxemia) and hence oxygen support is mandatory in such cases. But in this case, the SP02 was well within normal range only. Based on the available medical records it is clear that the insured patient’s vitals were stable through out admission, investigations are within normal and could have been managed under home isolation and it doesn’t require admission in a hospital. Hence, the Opposite Party had repudiated the claim and the same was informed to the Complainant on 07.03.2022. It is a cardinal rule of law that all provisions of law should be literally interpreted unless the provision or clause has an alternative construction to its ordinary meaning. The said rule of interpretation has been upheld by the Hon’ble Apex court in the case of Kishore Saraf v. Raw Cotton Co. Ltd 1963 SCR Supl. (2) 459. In a contract of insurance, the rights and obligations are governed by the terms of the said contract. The terms of the contract of insurance had to be strictly construed and no exception can be made on ground of equity. The terms of the policy have to be construed as it is and the court cannot add or subtract something. The said position of law is held by the Hon’ble Supreme Court in a decision reported in Surajmal Ram Niwas Oil Mills (P) Ltd. Vs. United India Insurance Co Ltd & Anr (2010) 10 SCC 567. Thereafter, the Complainant had submitted a letter on 28.03.2022, requesting to return all the original documents submitted by him and based on the request, the Opposite Party had returned the following documents to the Complainant vide letter dated 07.04.2022.
a) Original discharge summary.
b) Original final /main bills.
c) All other original bills.
d) Original lab reports.
e) Original X-ray film (1 no.)
f) Original ECG.
The allegations in the complaint are admitted only to the extent stated supra and the remaining is denied. The allegation of the Complainant that the policy is a cashless claim type policy is not correct and are denied. It is submitted that the policy issued to the Complainant has the cashless facility and reimbursement facility. The insured can opt both facilities based on their requirement. The further allegation of the Complainant is not fully correct and are denied. The Opposite Party had denied the request for cashless treatment for not submitting the details with regard to the COPD of the insured patient. There has been no deficiency of service whatsoever from the part of the Opposite Party in denying the preauthorization request for cashless treatment. Moreover from the treatment records, it was clear that the vitals were stable and did not require hospitalization as per the guidelines issued by AIMS, New Delhi and Ministry of Health and Family Welfare, Government of India. The Opposite Party had repudiated the claim as per the terms and conditions of the policy and as per the guidelines with regard to the Covid cases. The Complainant has not suffered any monetary loss and mental agony due to the acts of the Opposite Party. The Opposite Party has not committed any deficiency of service. The Complainant is not entitled for any of the reliefs as stated in the complaint. The Complainant has filed this complaint frivolously for the sole purpose of harassing these Opposite Party with intention for getting unlawful enrichment from the Opposite Party who is dealing with public money and functioning under the guideline of IRDA controlled by the Government of India. As public money is held in trust, the company must exercise abundant caution in dealing with claims by applying all conditions correctly. Hence, it is prayed to dismiss the complaint.
4. From the part of the Complainant, Ext.A1 and A7 marked. The Complainant adduced no oral evidence. From the side of the Opposite Party, no oral or documentary evidence adduced. The Complainant was finally heard on 10.07.2023.
5. On perusal of all the aspects of the case, Commission raised the following points for consideration
- Whether there has been any deficiency in service/unfair trade practice from the part of the Opposite Party?
- Relief and Cost if any, and the quantum.
6. Point No.1:- The allegation of the Complainant is that the Opposite Party repudiated his claim for cashless treatment and reimbursement on his insurance policy, though Covid-19 was diagnosed to his father and admission in hospital from 21.01.2023 to 24.01.2022, which is deficiency in service from the part of the Opposite Party and hence this complaint with prayers. On the other hand, admitting the policy of the Complainant, the Opposite Party contented that the cashless preauthorization request of the Complainant was denied as the hospital had not forwarded the copy of first consultation when (COPD) was diagnosed with exact duration and letter from treating doctor with seal and signature. Thereafter, claim for reimbursement of hospital expenses was denied as the patient’s vitals were stable and minor symptoms were only noted for which the Opposite Party depended upon the guidelines issued by AIMS, New Delhi and Ministry of Health and Family Welfare, Government of India with regard to covid cases. The Opposite Party also contented that “based on the available medical records, it was clear that the insured patient’s vitals were stable throughout admission; investigations were within normal and could have been managed under home isolation and it did not require admission in a hospital. It is seen that the insured (patient) is a citizen aged 65 years of age who was confirmed Covid-19 on 21.01.2022 from IQRA Hospital, Bathery. Being a senior citizen of 65 years of age, it is quite natural, that for the purpose of ensuring the health and safety of the person, to seek treatment in hospital having more specialized and modern facilities. Here, in this case, it is seen that on diagnosing Covid-19, the patient was transferred from IQRA Hospital and admitted in DM WIMS, Wayanad. In each case of disease and depending upon the health condition of a patient, the requirement of admission in hospital is decided by the concerned doctor of the hospital. Therefore, the contention of the Opposite Party that “the insured person’s vitals were stable throughout admission; investigations were within normal and could have been managed under house isolation and did not require admission in a hospital” is not sustaining. Moreover, the amount of reimbursement claimed is only Rs.25,729/-. It cannot be believed by an ordinary prudent person that a senior citizen having 65 years of age should voluntarily get hospitalization and try to stay in the hospital for four days so as to get a small claim amount of Rs.25,729/-. In addition, on going through the discharge summary issued by DM WIMS Hospital, Wayanad the clinical parameter of BP (Blood Pressure) is seen recorded as 190/100 mm hg (120/80 is normal) which is seen very higher. So, the contention of the Opposite Party that the insured patient’s vitals were stable throughout admission is not standing, but false. In view of the above discussion, we are of the view that nothing is seen wrong in hospitalization and treatment of the insured person. Therefore, the Opposite Party ought to have accepted and reimbursed the insurance claim of the Complainant, but they repudiated the claim of the Complainant with unsustaining contentions, which is nothing but deficiency in service/unfair trade practice from the part of the Opposite Party. Other contentions and arguments of the Opposite Party are immaterial as to the facts and circumstances of the case and hence discarded. So, Point No.1 is proved against the Opposite Party.
7. Point No.2:- As Point No.1 is against the Opposite Party, they are liable to reimburse the insurance claim of the Complainant, pay compensation for deficiency in service and cost of this complaint.
In the result, the complaint is allowed and the Opposite Party is directed to
- Reimburse Rs.25,729/- (Rupees Twenty Five Thousand Seven Hundred and Twenty Nine Only) being the amount of insurance claim
- Pay Rs.15,000/- (Rupees Fifteen Thousand Only) towards compensation and
- Pay Rs.10,000/- (Rupees Ten Thousand Only) towards cost of this complaint.
The above amounts shall be paid to the Complainant within one month from the date of this Order, failing which the amount will carry interest @ 8% per annum from the date of this Order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 1st day of August 2023.
Date of Filing:-22.04.2022.
PRESIDENT :Sd/-
MEMBER :Sd/-
APPENDIX.
Witness for the Complainant:-
Nil.
Witness for the Opposite Party:-
Nil.
Exhibits for the Complainant:
A1. Discharge Summary.
A2. Letter of Repudiation of Claim. Dt:07.03.2023.
A3. Rapid Antigen Test Report. Dt:21.01.2022.
A4. Result Report Biochemistry Lab. Dt:21.01.2022
A5. HRCT CHEST Report. Dt:22.01.2022.
A6. IP Final Bill.
A7. Cash Receipt. Dt:24.01.2022.
Exhibits for the Opposite Party:-
Nil.
PRESIDENT :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR
CDRC, WAYANAD.
Kv/-
