BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 28^TH DAY OF NOVEMBER 2022

ORDER

SMT.M.SHOBHA, PRESIDENT

1. The complaint has been filed under Section 35 of C.P.Act (hereinafter referred as an Act) against the OP praying this Hon’ble Commission to allow the claim of Rs.53,427/- along with interest and such other relief as applicable in favour of the complainant.
2. The case set up by the complainant in brief is as under:-

The complainant has taken a medical insurance policy from Oriental insurance company on 06.08.2006 and it was continuously renewed without any break. Subsequently he ported the policy to the OP company on 06.08.2018 and he used to renew the policy punctually without any default. He is having the health insurance policy bearing No.P/141113/01/2021/006746 commencing from 06.08.2020 to 05.08.2021.

3. It is the grievance of the complainant that he was admitted to Brindavan Aerion Hospital at Chamarajpet for Covid-19 illness category A and hypertension.   He was treated for the same and discharged on 24.09.2020.  He has paid a total hospital expenses of Rs.1,56,423/-. After that he had applied for reimbursement of the amount.  He has received an initial claim amount of Rs.80,926/- on 04.12.2020 and Rs.76,997/- on 28.12.2020 and even after this there was a deduction of Rs.64,497/-.  After he raised this issue with the Claim Manager and Grievance Redressal Officer an additional amount of Rs.12,570/- was paid by the OP on 13.01.2021 and totally he has received Rs.1,05,996/-.

4. It is further grievance of the complainant that he was administered Remidisvir for treating covid 19 and the same is mentioned in the discharge summary and also reflected in the bill summary.  The claim manager and grievance redressal officer has deducted Rs.32,400/- towards Remidisvir alleging that it was not indicated to the current ailment, hence the total amount of Rs.32,400/- was deducted.  

5. It is further grievance of the complainant that he was admitted to the hospital treating patients infected with covid 19 with Remidisvir was a protocol to ensure the infection was reduced and no further complications had to be faced by the patients.  In such a scenario he was administered with Remidisvir by the hospital who being the health professional felt it necessary to save the life of the complainant.  He has also relied on the article published by National Library of Medicine, in October 2020 indicates that Remidisvir is an important drug to cure covid 19.  Hence the rejection of the claim by the OP that the injection administer by the experts at the hospital is not indicated to the current ailment is totally wrong.  Even though there was a notification against the use of Remidisvir for covid patients, Government of India in their article listed at

6. It is further case of the complainant that the office of the insurance ombudsmen forum noted the guidelines issued by the GIC for the settlement of the covid 19 claims missed considering this valid point while addressing the complaint of the complainant and disallowed the complaint filed by the complainant.  Hence the complainant has filed this complaint.  

7. In response to the notice, OP appears and files version admitted the policy issued by them in favour of the complainant, stating that the complainant avail the insurance policy vide policy No.P/141113/01/2021/006746 for the period from 06.08.2018 to 05.08.2019 and again it was renewed from 06.08.2020 to 05.08.2021 for the cashless of medical expenses.  

8. It is the case of the OP that the policy is contractual in nature and the claims arising therein are subject to terms and conditions forming part of the policy.  The complainant has accepted the policy agreeing and being fully aware of the terms and conditions and executed the proposal form.  As per the discharge summary the insured was diagnosed with covid 19 illness category A hypertension.  This OP have settled on 03 to 04 occasions totally a sum of Rs.1,05,996/-.  

9. It is the specific contention taken by the OP that they have deducted Rs.4,700/- as it is spent for registration fee and it is excluded items of the policy.  Further the expenses towards vasofix, easyfix, antiflew, tegaderm, chlorhexidine, entavir,  are not payable and they are excluded items of the policy. Remidisvir is not indicated to the current ailment and hence they have deducted Rs.34,727/-.  As per covid 19 inpatient tariff guidelines, as per Government of Karnataka Rs.12,500/- for five days payable.  Hence Rs.62,500/- was allowed and deducted Rs.12,500/-.  
10. It is further case of the OP that the claim of the amount under post hospitalization expenses, as per NABL rate CBC Rs.150/-, CRP 100/-, ferritin Rs.200/-, D-dimer Rs.800/- only payable.  Further as per other excluded items of the policy, the expenses towards service registration are not payable and hence they have deducted Rs.1,500/-.  Hence they have deducted an amount of Rs.53,427/- out of the total amount claimed Rs.1,56,423/-.  They have paid the maximum payable.  It is settled law that the terms of the policy shall govern the contract between the parties. Hence this Op company and the complainant have to follow all terms and conditions of the policy correctly.  The companies liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured for family as mentioned in the schedule.  There is no cause of action for the complainant. The relief sought for Rs.53,427/- towards hospitalization expenses is not payable as per the terms of the policy and the claim amount was settled for Rs.1,05,996/-. Hence OP prayed for dismissal of the complaint.  

11. The complainant has filed her affidavit evidence and relies on 05 documents.  Affidavit evidence of OP has been filed and OP relies on 07 documents.

12. Though sufficient opportunity was given to both the parties, have not addressed their arguments. Hence posted for orders.

13.     The following points arise for our consideration as are:-

1. Whether the complainant proves deficiency of service on the part of OP?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

14.   Our answers to the above points are as under:

       Point No.1:  Affirmative

      Point No.2: Affirmative

      Point No.3: As per final orders

REASONS

15.    Point No.1 AND 2: Perused the complaint, version and the documents filed by both the parties.

16.     It is undisputed fact that the complainant has taken the policy from the OP company for comprehensive coverage.  It is also undisputed fact that the complainant was hospitalized for a period of 19.09.2020 to 2409.2020 due to covid 19 and after the discharge he applied for reimbursement of claim amount of Rs.1,56,423/-.  The OP have settled the amount in three stage for Rs.1,05,994/.  They have deducted an amount of Rs.32,400/- towards Remidisvir on the ground that it was not indicated to the current ailment.  

17.     On the other hand the contention taken by the OP is that they have settled the maximum amount on the basis of the claim made by the complainant and they have deducted only Rs.53,427/- and hence they are not liable to pay any amount.  

18.     The complainant in support of his contention has filed his affidavit evidence and relied on five documents.  Ex.P1 is the copy of the policy and the premium receipt, Ex.P2 is the Discharge Summary issued by the hospital and Ex.P3 is the bunch of bills reports and authorization from page 32 to 63 and Ex.P4 is the copy of application of National Library of medicine and Ex.P5 is the copy of the order passed by the Insurance Ombudsmen.  The complainant has reiterated all the allegations made in the complaint.  

19.     On the other hand, the Assistant Manager, Legal of the OP company filed her affidavit evidence and relied on 07 documents as Ex.R1 to R7.  Ex.R1 is the copy of the schedule of the Policy, Ex.R2 is the copy of the terms and conditions of the policy, Ex.R3 is the copy of claim form, Ex.R4 is the copy of the Discharge summary and Ex.R5 is the copy of the medical records and Ex.R6 is the copy of the GIC guidelines for Covid 19 and Ex.R7 is the billing sheet.

20.     The only dispute between the complainant and the OP is that the OP have deducted an amount of Rs.53,427/- without any basis and they have no authority to deduct the amount of Rs.32,400/- towards Remidisvir medicine alleging it was not indicated to the current ailment.  

21.     It is clear from the medical report submitted by the complainant that the complainant was admitted to the hospital, when the hospital was treating patient infected with covid 19 with Remidisvir, which was protocol to ensure the infection was reduced and no further complications has to be faced by the patients.  In such a situation the hospital who being the health professional, felt it necessary to administer the drug Remidisvir to save the life of the patient i.e., the complainant.

22.     The complainant has also relied on the article published by National Library of Medicine and also the notification issued by the Government of India in their article listed at

23.     It is clear from the terms and conditions of the policy the treatment for covid is not excluded from the policy.  Under these circumstances the OP had to pay the expenses borned by the complainant for the said treatment.  If really the Remidisvir is not indicated to the current ailment according to the OP they would have examined any doctor or they would have submitted report from an expert doctor stating that the drug Remidisvir administered by the hospital to the complainant is wrong and the hospital authorities would have administered other drugs other than Remidisvir to save the life of the complainant.  The OP without any basis have simply deducted an amount of Rs.32,400/- spent by the complainant for purchasing Remidisvir medicine as per the advise of the doctors.

24.     The complainant has taken the policy in order to take the best treatment from the best hospitals and the best expert doctors.  Hence he was admitted to a best hospital and taken the best treatment and the hospital authorities have saved the life of the complainant by administering the drugs and which is not at all excluded from the medical board or by the drug controller at that time.  On the other hand, this medicine is treated as a life saving drug during covid period and all the hospital authorities were treating the patients with this drug and it is also supported by the Government notification.  Even though the complainant has taken the medicine as per the advise of the doctors the OP without any basis have deducted the amount of Rs.32,400/- and the decision taken by the OP is not proper and correct and hence it has to be rejected.

25.     The complainant has clearly established that even though he was having a valid policy and has taken treatment by spending the huge amount of Rs.1,56,420/- and the policy was in force the OP have refused to pay the amount on the only reason that the drug was not indicated to current ailment. In view of this the complainant has suffered mentally and financially.  Even though the complainant has approached the office of the insurance ombudsmen, his claim was rejected.  The OP company have made the complainant to run from pillar to post to get the entire reimbursement and even though it is within the insured amount.  Hence the complainant is entitled for Rs.53,427/- with compensation of Rs.20,000/- and litigation expenses of Rs.10,000/-.  Hence we answer point No.1 and 2 in affirmative.

26.    Point No.3:- In view the discussion referred above, we proceed to pass the following;

O R D E R

1. The complaint is allowed in part.
2. The OP is directed to pay Rs.53,427/- with compensation of Rs.20,000/- and litigation expenses of Rs.10,000/- to the complainant.
3. The OP shall comply this order within 60 days from this date, failing which the OP shall pay interest at 8% p.a. after expiry of 60 days on Rs.53,427/- till final payment.
4. Furnish the copy of this order and return the extra pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 28^TH day of NOVEMBER, 2022)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party – R.W.1;