D.O.F:29/01/2021
D.O.O:08/12/2023
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KASARAGOD
CC.26/2021
Dated this, the 08th day of December 2023
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SMT.BEENA.K.G : MEMBER
S. Mahesh Sharma, aged 54 years
S/o Mahabala Sharma S.
Residing at Mahalakshmi Nilaya
Sampathila, P.O. Nekraje
Kasaragod taluk and District – 671543.
(Adv: Shivashankar Bhar)
: Complainant
And
- Star Health and Allied Insurance Co.Ltd
No. 15, Sri Balaji Complex, 1st Floor, Whites Lane,
Rayapettah, Chinnai – 600014.
- Star Health and Allied Insurance Co. Ltd
Branch office – 2nd Floor, Aramana Arcade,
Bank Road, Kasaragod – 671121.
(Adv: Vinod Kumar K, for OP 1&2) : Opposite Parties
ORDER
SMT.BEENA.K.G : MEMBER
The brief facts of the case is that, the complainant is a policy holder under Star Health and Allied company Ltd and another (opposite party) having policy No. P/181325/01/2020/001614 for Medi Classic Insurance Policy revised in 2019. And the insurance policy covers the period from 31 March 2020 to 30 March 2021. The aforesaid insurance policy covers several benefits as mentioned specifically in the policy include several deceases. The complainant was suffering from fever, headache and cough from 07/11/2020 onwards continuously and on 10/11/2020 after tests, it was diagnosed as Covid-19 CAT, type 2 D.M and was under quarantine at home under the treatment of Dr. Jayadev Kangila, Carewell Hospital, Kasaragod. On 14/11/2020, the condition of the complainant became serious as there was difficulty in breathing and on advice of the doctor, he was shifted to the hospital and was admitted as inpatient for 7 days and discharged on 20/11/2020. At the time of discharge, the opposite party denied to approve the claim for cashless treatment. The normal procedure as per the policy is that once cashless hospitalization for health insurance claim form was submitted to opposite party through the hospital authorities, the amount shall be directly paid by the insurer to the hospital. But the complainant’s cashless payment was denied by repudiation letter dated 20/11/2020 due to the reason that cashless facility cannot granted to a patient who have only mild symptoms. Such patient can be well managed under home quarantine itself. But the opposite party advised the complainant to submit the document for reimbursement of the expenses incurred relating to the treatment. Even though the complainant submitted all the documents as on 23/11/2020 to the opposite party, they repudiated the claim for reimbursement by letter dated 02/11/2021. The allegation of the complainant is that his claim was rejected in an arbitrary manner and it is a breach of policy condition. The attempt of the opposite party is to make unlawful gain at the expenses of complainant, which is not permitted in law. The complainant suffered financial loss and damage due to mental agony. Therefore, the complainant claims for refund of the amount Rs.60,933/- with 12% interest from 20/11/2020 to till reimbursement along with a compensation of Rs.1,00,000/- for mental agony.
According to opposite party, all the averments and allegations made in the complaint except which are specifically admitted here are denied. The complainant has no bona fides in instituting the complaint and it has been done with ulterior motive of making illegal gains. The opposite party further admits that the complainant took a Mediclassic Insurance Policy from the branch of Kannur on 31/03/2014 for a sum insured of Rs. 2,00,000/- which has been renewed up to 30/03/2021 vide policy No.P/181325/01/2020/001614. At the time of issuing the policy, the complainant have supplied with the terms and conditions of the policy. And which is also explained to him at the time of proposing policy and the same was served to the complainant along with the policy schedule. The opposite parties had received a pre-authorization request from Carewell hospital Kasaragod stating that the complainant was admitted at the hospital on 14/11/2020 and was provisionally diagnosed with Covid-19. After receiving the preauthorization request from the hospital, the opposite parties had requested the hospital to forward the detailed ICPs till date. Thereafter the hospital has forwarded the case sheets and other details. As per the records, the complainant has only mild symptoms afebrile and well oriented and hemodynamically stable. As per the guidelines issued by AIIMS, for mild symptoms the patient can be well managed under home quarantine itself. Hence the opposite parties had denied the pre-authorization request for cashless treatment and informed this to the hospital by letter dated 20/11/2020. After the treatment were over, the complainant had submitted claim form with all other documents to the opposite party. In a Covid case, the primary symptoms are fever, sore throat, headache, chills, loss of smell or taste, conjunction or runny nose, vomitting, diarrhea and low level of SpO2 etc. SpO2 is Oxygen saturation, is the 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 efficiently. In fact, very low level of SpO2 can result in very serious respiratory symptoms. Based on the available medical records, the complainant’s vital are stable and stayed at hospital only for the observation. Hence opposite parties had repudiated the claim. After repudiation of the claim, the complainant had submitted a representation to reconsider his claim. After the receipt of the representation, the opposite parties had reviewed the claim and was decided not to alter the decision taken earlier. Therefore, the complainant is not entitled for any relief as stated in the complaint.
The complainant filed proof affidavit in lieu of chief examination and was cross examined as PW1. The documents produced are marked as Ext.A1 to A9. Both sides heard and documents perused. The main issues raised for consideration are;
- Whether the repudiation of claim of the complainant by the opposite party is arbitrary?
- Whether the complainant is entitled for relief?
- If so, what is the relief?
For convenience, all points can be considered together. The complainant is a Medi classic insurance policy holder of opposite parties. The said insurance policy covers several benefits as mentioned specifically in the policy includes several diseases. From 07/11/2020 onwards, the complainant was suffering from fever, headache, cough etc. and on 10/11/2020, after test, it was diagnosed as Covid-19. And he was under the treatment of Dr. Jayadev Kangila of Carewell hospital Kasaragod. On 14/11/2020, the complainant’s condition became serious. As he had difficulty in breathing and as per the advice of the doctor, he was shifted to hospital and was admitted as inpatient for 7 days. The complainant was discharged on 20/11/2020. On discharge, the opposite party denied to approve the cashless treatment of the complainant and he was constrained to pay Rs.60,933/-. Ext.A1 is the discharge summary, Ext. A2 is the Discharge bill, report of Covid-19 test are marked as Ext.A3 & A4. CT scan report is Ext.A5. The claim form and rejection letter is marked as Ext.A6 & A7. The complainant again submitted claim form for reimbursement of hospital expenses dated 23/11/2020 and the repudiation of the claim are marked as Ext.A8 & A9. Due to the repudiation of the claim, the complainant was constrained to borrow money from friends and relatives to pay the hospital bill, which caused severe mental agony and loss to the complainant. The complainant suffered damages due to the illegal act of opposite party. On perusal of the documents submitted by the complainant, we are of the view that he is seriously suffering from Covid-19 and he deserves reliefs. The Opposite party is bound to comply the conditions of the policy. The purpose of issuance of such a policy is to financially assist the policy holders. In the beginning stage, the “Covid-19” created an apprehension in the minds of the entire public. So, the insurance companies commenced a new policy to attract the people. But after joining and paying the amount, rejecting the claim, mentioning silly reasons is illegal. The opposite parties are bound to allow the claim with compensation and cost. Therefore, the opposite party is bound to pay the bill amount of Rs.60,933/. The prayer of the complainant is to pay the bill amount of Rs.60,933/- with 12% interest from 20/11/2020 till disbursement with a compensation of Rs.1,00,000/- along with cost of the proceedings. The compensation claimed by the complainant is Rs.1,00,000/- which is excessive and without any basis. Considering the circumstances of the complainant, an amount of Rs.50,000/- is a reasonable compensation.
In the result, complaint is partly allowed directing opposite parties to reimburse the bill amount of Rs.60,933/- (Rupees Sixty thousand Nine hundred and Thirty Three only) with 9% interest from 20/11/2020 till reimbursement along with a compensation of Rs.50,000/- (Rupees Fifty thousand only) and a cost of Rs.5,000/- (Rupees Five thousand only) to the complainant within 30 days from the date of receipt of copy of this order.
Sd/- Sd/-
MEMBER PRESIDENT
Exhibits
A1 – Discharge summary
A2 – Discharge bill
A3 – Covid-19 test report
A4 - Covid-19 test report
A5 – CT scan report
A6 - Claim form
A7 - Rejection letter
A8 – Claim form
A9 – Repudiation of claim
Witness cross-examined
PW1 – Mahesh Sharma
Sd/- Sd/-
MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
JJ/
