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 Parties are dealing with the business of Health insurance and other insurance products.  The Complainant is an agriculturist.  The Complainant had joined in the Health Insurance Policy Scheme of the Opposite Parties for himself and his wife. The period of coverage was from 27.06.2022 to 26.06.2023.  In the meanwhile, on 26.08.2022, wife of the Complainant was admitted at Meitra Hospital Kozhikode for Cardiac problems and was discharged on 27.08.2022 and a total sum of Rs.28,149/- was spent for the treatment.  The Complainant claimed the amount spent for treatment by producing all the documents demanded by the Opposite Parties.  But they extended the payment without any reason.  Subsequently, on 09.11.2022, the Opposite Party No.2 sent a letter intimating that the required documents were not produced by the Complainant. The Complainant had produced the entire documents as required by the Opposite Parties.  According to the Hospital authorities also, the entire documents required for processing of the claim was furnished by them.  The documents such as bills, consultation details, investigation reports, certificates of doctor etc.. were furnished to the Opposite Parties.  But the Opposite Parties purposefully repudiated the claim only for the purpose of avoiding or delaying the payment of insurance amount to the Complainant.  The Complainant had availed the medi-claim insurance protection for his wife and himself for which an amount of Rs.29,942/- were paid towards premium.  The denial of the claim amount by the Opposite Parties is against natural justice and the  terms and conditions of the policy.  The claim was denied without any valid grounds.  Because of the unfair trade practice of the Opposite Parties, the Complainant had suffered great mental agony, loss and difficulty.  Hence the Complainant has approached the Commission praying

1. To direct the Opposite Parties to pay a sum of Rs.28,149/- towards the treatment expenses with interest @ 12% from 27.08.2022 till the date of payment.
2. To direct the Opposite Parties to pay a sum of Rs.50,000/- being the damages to the Complainant and
3. To direct the Opposite Parties to pay the cost of this complaint.

3.  Upon getting summons, the Opposite Parties appeared before the Commission and filed joint version for Opposite Party No.1 to 3. The contents of version in brief are the following:-

The Complainant had taken the Health Insurance Policy from the Opposite Parties for a sum insured of Rs.5 lakhs from 27.06.2022 to 26.06.2023.  The policy was meant for the coverage of the Complainant and for his wife.  The terms and conditions of the policy was issued to the Complainant at the time of taking the policy. The Complainant has admitted the terms, conditions and exclusions set in the policy.  The Complainant had requested for cashless hospitalization from Meitra Hospital stating that the Complainant’s wife was admitted at the Hospital on 26.08.2022 and provisionally diagnosed with Coronary Artery Disease, ACS, unstable angina.  Along with the pre-authorization request, the Hospital had forwarded only the present treatment records without providing the first consultation details with exact duration of coronary artery disease, copies of investigations etc and hence the Opposite Parties could not process the claim of the Complainant.  Therefore, the pre-authorization request for cashless treatment was denied and it was informed to the Hospital and the Complainant by letter dated 27.08.2022. After discharge of the wife of the Complainant on 26.08.2022, the Complainant had submitted discharge summary and bills for reimbursement of the claim.  In this regard, the Opposite Parties had issued a query letter dated 06.10.2022 to the Complainant requesting to submit the first consultation details and the copies of investigation, past admission etc..  But even after repeated reminders, the Complainant had not provided the required documents to the Opposite Parties.  This is the violation of condition No.D(18) of the policy.  Hence the Opposite Parties had repudiated the claim wide letter dated 09.11.2022.  The Complainant had not submitted certificate of Doctor explaining the first consultation details with exact duration of CAD. Other allegations of the Complainant are denied.  The Complainant has filed this complaint vexatiously and frivolously for the sole purpose of harassing the Opposite Party with intention of getting unlawful enrichment from the Opposite Party who are dealing with public money.  Hence the Opposite Parties prayed to dismiss the complaint with compensatory cost.

4.  Chief affidavit was filed by the Complainant, Ext.A1 and A2 were marked from his side and he was examined as PW1.  From the side of Opposite Parties, Ext.B1 was marked but no oral evidence was adduced.  The Complainant was finally heard on 05.08.2024.

5.  On perusal of the complaint, version, affidavits, documents marked and the oral evidence adduced by PW1 as well as the arguments of the Counsels for the Complainant and Opposite Parties, 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 Parties?
2. Relief and Cost….?

6. Point No.1:-   It is the admitted fact that the Complainant had availed the Health Insurance Policy from the Opposite Parties on 27.06.2022 for the Complainant and his wife.  The period of coverage of the policy was from 27.06.2022 to 26.06.2023. It is also not disputed that the Complainant’s wife was treated in Meitra Hospital, Kozhikode.  The main allegation of the Complainant is that though he had a valid insurance policy with health coverage for his wife and himself, the Opposite Parties without any valid reasons repudiated the claim of the Complainant requesting claim amounts which was incurred in respect of the treatment of his wife.  The contention of the Opposite Parties for repudiating the claim is that the Complainant has not produced details regarding the previous treatment as required by the Opposite Parties and hence they could not process the claim application of the Complainant.  Commission made a thorough probe into the detailed aspects of the case.  In cross-examination of PW1 he has stated that “Meitra Hospital, tImgnt¡mSv ImWn¡p¶Xn\v ap³]v ChnsS Hospital  ImWn¨ncp¶nÃ.  NnInÕ kw_Ôn¨v BZytcJIÄ FXrI£n Hospital  tNmZn¨ncp¶p.  R§Ä ap³]v NnInÕn¨n«nÃ.  BZy tcJIÄ Hospital sImSp¯n«nà F¶p ]dªm icnbÃ.  NnInÕsb kw_Ôn¡p¶ FÃm tcJIfpw sImSp¯n«p­v”.  PW1 further deposed that “BZy NnInÕ kw_Ôamb Imcy§fpw tcJIfpw ad¨v h¨v tcJIÄ lmPcm¡nbnà F¶p ]dªm icnbÔ.  Here, the Opposite Parties had informed to produce the previous treatment records but the Complainant has stated in oral evidence that the Complainant’s wife was not treated previously.  It is to be seen that the Complainant cannot produce previous treatment records if there was no previous treatment.  The Opposite Party has failed to prove that the Complainant’s wife had previous treatment.  A person cannot be compelled to perform an impossible act of producing documents which are not in existence.  So, the contentions of the Opposite Parties that the Complainant and the Hospital willfully not produced the previous treatment records cannot be accepted.  Commission finds that, here, the Opposite Party has repudiated the claim of the Complainant without any valid and sustainable grounds.  In version, it has been stated by the Opposite Parties that the Complainant has filed this complaint vexatiously and frivoulsy for the sole purpose of harassing the Opposite Parties with the intention for getting unlawful enrichment from the Opposite Party.  But from the facts and circumstances of the case, it is undoubtedly seen that the Opposite Parties have repudiated the claim of the Complainant with an evil motive to make undue enrichment of money from the Complainant without allowing the claim of the Complainant.  This act of the Opposite Parties is clear deficiency in service/unfair trade practice which cannot be appreciated.  So Point No.1 is proved in favour of the Complainant.

7.  Point No.2:-  As point No.1 is proved in favour of the Complainant, he is entitled to get the claim amount together with interest, compensation and cost of this complaint.

In the result, the complaint is partly allowed and the Opposite Parties are directed

1. To pay a sum of Rs.28,149/- (Rupees Twenty Eighty Thousand One Hundred and Forty Nine Only) towards the treatment expenses together with interest @ 9% per annum from the date of this complaint till the date of payment.
2. To pay a sum of Rs.15,000/-(Rupees Fifteen Thousand Only) towards damages/compensation.
3. To pay a sum of Rs.5,000/- (Rupees Five Thousand Only) towards cost of this complaint.

The above amounts shall be paid jointly and severally by the Opposite Parties to the Complainant within 30 days from the date of receipt of this Order, failing which the above amounts will carry interest @ 9% 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 3^rd day of September 2024.

Date of Filing:-15.03.2023.

PRESIDENT   : Sd/-

MEMBER       : Sd/-

MEMBER       : Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              T. J. Jose.                                                                   Agriculture.

Witness for the Opposite Parties:-

                        Nil.     

Exhibits for the Complainant:

A1.                  Copy of Star Health Assure Insurance Policy Schedule for the

period of 27.06.2022 to 26.07.2023.

A2.                  Copy of Repudiation Letter.                                Dt:09.11.2022.

Exhibits for the Opposite Parties:-

B1.                  Copy of Policy Schedule and Conditions.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

/True Copy/

Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-