The case of the complainant is that the complainant is the insurance policy holder under O.P No.1 being policy No. P/161130/01/2022/03592 valid from 22/06/2021 to 21/06/2022 by paying premium of Rs. 34,822/- and he purchased the said policy online through policy bazaar and it is health insurance covered at 20 lakhs which includes the complainant and his wife and son. That on 08/04/2022 at night the complainant suffered a stomach pain after dinner and his stomach became upset and diary and vomiting started and he took some common medicine to get control over the said problem of his stomach but the medicine did not work. The body of the complainant started dehydrated in the morning at 09/04/2022 and his condition became deteriorated. His father took him to the chamber of Dr. Mohit Kumar Santra at Alipurduar who after examining the patient advised to get admit in the Green Land Nursing Home, Alipurduar for proper treatment. The complainant as per advise of the doctor was admitted in the Green Land Nursing Home, Alipurduar on 09/04/2022 wherein he was treated properly and he was discharged from the Green Land Nursing Home, Alipurduar on 12/04/2022. The complainant had to pay Rs. 8,427/- to the Green Land Nursing Home, Alipurduar for the medicine charges, registration, bad charge etc. The complainant also paid Rs. 4,000/- as doctor fees during his treatment. After return from the Green Land Nursing Home, Alipurduar he went the Apollo Hospital, Chennai for better treatment as he was not feeling well. In Apollo Hospital he had to undergo several test and consulted with the Apollo doctors and huge expenses to the tune of Rs. 72,152/- were incurred by the complainant for his treatment in both Green Land Nursing Home, Alipurduar and Apollo Hospital, Chennai. The complainant duly intimated to the O.Ps insurance company about his admission of Green Land Nursing Home, Alipurduar and submitted all related documents bills and money receipt in original and the O.Ps acknowledges the same for reimbursement. But unfortunately the legitimate claim of the complainant has not been considered and settled any amount by the O.Ps for reason that the medical team of the O.Ps was of the opinion that the insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted and the same was intimated to the complainant by the O.Ps by letter dated 30/06/2022 prior to issuing the said letter the O.Ps asked the complainant to submit documents as per their requirement and the complainant complied those letters in due time. The O.Ps insurance company willfully and deliberately repudiated the legitimate claim of the complainant on the untenable ground and thereby assassinated the faith and trust of the complainant and the complainant get mental pain and agony due to the harassment caused by the O.Ps. There is gross negligence and deficiency in service in respect of settlement of the legitimate claim of the complainant. The complainant has filed this case with a claim of Rs.70,152/- for medical expenses and also claim Rs. 50,000/- as compensation for his mental agony and harassment and also Rs. 20,000/- as litigation cost.
All the O.Ps have contested by filing written version wherein they have denied all the material allegations made by the complainant. O.Ps an admitted that the complainant and his wife and son was covered under health insurance policy and which was subsequently renewed till 21/06/2022. The case of the ops is that after filing the claim petition the O.Ps asked the complainant to submit all the hospital bills, registration certificate, indoor test papers, discharge summary investigation papers etc. from the complainant. Upon received of the present complaint O.Ps submitted that they have considering and settling the claim of Rs. 46,915/- as per terms and condition of policy as well as IRDA guidelines. He has specifically mentioned that the deduction of the bills in his written version. The O.Ps further stated that they are ready to settle the amount of Rs. 46,915/-. He further stated that the complainant did not approached before the grievance Department from the O.P Nos. 1 and 2. They have prayed for dismissal of the case.
We have gone through the materials on record very carefully and also perused the documents which are lying on case record. Considering the above pleadings the following issues are necessarily come up for the proper adjudication of this case.
POINTS FOR CONSIDERATION
- Is the complainant a consumer u/s. 2(7)(ii) of Consumer Protection Act, 2019 ?
- Has this Commission jurisdiction to try the instant case?
- Is there any deficiency in service on the part of the O.Ps?
- Is the complainant entitled to get any relief/reliefs as prayed for?
DECISION WITH REASONS
Considering the nature and character of the case all these points are interlinked to each other as such all the points are taken up together for consideration for the sake of brevity and convenience. The case has been filed u/s. 35 of the Consumer Protection Act, 2019 by the complainant.
Point Nos. 1 & 2:-. Admittedly the complainant is the insured under O.Ps for an health insurance amounting to Rs. 20 lakhs and he paid the premium accordingly and the said insurance policy was renewed upto 21/06/2022. So he is the consumer as per law as he is the policy holder by making payment of premium and the said policy was enforced till 21/06/2022. So, there is no hesitation to hold that the complainant is a consumer within the meaning of u/s. 2(7)(ii) of C.P. Act, 2019 and the complainant and his family members resides within the territorial jurisdiction of this Commission and the O.Ps runs their business at Alipurduar through O.P No. 3 which is within the territorial jurisdiction of this Commission. Therefore, this Commission has territorial jurisdiction to try this case as per u/s. 34 of C.P. Act, 2019.
Point Nos. 3 & 4:- It is an admitted position that the complainant along with his wife and son covered with an health insurance policy amounting to Rs. 20 lakhs with the O.Ps by making payment of premium and the said policy was enforced till 21/06/2022. It is the allegation of the complainant is that he became sick for his stomach etc. with some abdominal pain and he was treated by Pro-forma O.P No. 1 at his chamber who advised him to admit in the Green Land Nursing Home, Alipurduar of Pro-forma O.P No. 2. Accordingly he was admitted there on 09/04/2022 where he was treated by the Pro- forma O.P No. 1 and ultimately he was discharged on 12/4/2022. Annexure - A regarding the health insurance policy and it is renewal Annexure - B is the advise of doctor for admission of the nursing home Annexure C is the bill of nursing home Annexure - D is the money receipt of the nursing home and also the money receipt of the doctor fees. The further case of the complainant is that he went to Apollo Hospital, Chennai for better treatment where he was asked to some pathological test and also consulted with the doctor and in total his expenses was Rs. 70,152/- including the medical costs of Alipurduar. He has filed the claim petition before the O.Ps which is Annexure - E it appears that the O.Ps asked the complainant to file some documents which is Annexure - G and the complainant submitted the said documents to the O.Ps by an acknowledge issued by the O.Ps. Ultimately on 30/06/2022 by Annexure - F the O.Ps have repudiated the claim on the ground that hospitalization was not warranted as their medical team opined. But again the complainant by sending an e-mail and request the O.Ps to reconsider their claim but the O.Ps did not reconsider the same. O.Ps stated that the complainant did not submit all the documents and after filing this case they are ready to settle the dispute with amounting to Rs. 46,915/- after deducting some costs which the complainant is not entitled to get any benefit according to IRDA rules. After considering all the documents as well as the evidence and argument of the parties we find that the complainant was admitted to the nursing home at Alipurduar for his treatment as per advise of the doctor and he made some payments for nursing home bills as well as doctor fees the document is there he also find that the complainant sent to Apollo Hospital, Chennai for his treatment and he submitted all the documents to the O.Ps regarding payment was made but unfortunately the O.Ps repudiated the claim on the ground that their medial team opined that the insured patient could have been managed as an outpatient and hospitalization of the insured patient was not warranted. We find that the doctors advised the complainant to admit in the hospital. The complainant himself did not admit in the nursing home. So the opinion of the medical team is not at all tenable when the expert opinion is there. It also appears that the complainant has submitted all the bills and documents to the O.Ps but the O.Ps did not consider the same and repudiated his claim. The ground of the O.Ps is that as per IRDA guidelines the complainant is not entitled to get some expenses which amounting to Rs. 780/- according to written version Para-12v(i) but the other claim O.Ps in his written version and evidence stated some deduction which we find is not tenable at all. The doctor himself issued the receipt of his fees which is Annexure - A but that fees is not included in the nursing home charge so why this amount shall not be paid is not clear before this Commission and the O.Ps whimsically deducted some amount from the total claim of the complainant according to his own accord. There is no reason of that deduction that a part another very curious thing is there that at first the O.Ps repudiated the claim of the complainant on the ground that their medical team did not agree to pay the said claim amount. But after filing this case the O.Ps in their written version stated that they are ready to settle the dispute with an amount of Rs. 46,915/-. If the medical team of the O.Ps opined that the complainant is not entitled to get any claim then after filing of the case why they were ready to settle the same with reduce amount? That means that the complainant was entitled to get the claim which the O.Ps intentionally by way of negligence and deficiency in service at first repudiated the same and when they found that a case has been filed then they were ready to settle the same to save their scheme which means the complainant is entitled to get the claim amount except Rs. 780/- which he is not entitled as per IRDA rule. There is a completely deficiency in service from the part of the O.Ps. They are taking premium year to year from the complainant and when the claim petition is filed they tried to discard the said claim by a flimsy ground. We find that the complainant is entitled to get the entire amount except Rs. 780/- from the O.Ps as he is valid insurer and his policy was valid during the claim. There is a gross negligence from the part of the O.Ps and deficiency in service. The complainant is entitled to get compensation of Rs. 40,000/- for his mental agony, harassment and suffering and also entitled to Rs. 10,000/- as litigation cost..
Thus all the points are disposed of accordingly in favour of the complainant.
Hence, for ends of justice; it is;-
ORDERED
that the instant case be and same is allowed on contest against the O.Ps. The complainant do get an award amounting to Rs. 69,372/- (Sixty Nine Thousands Three Hundred Seventy-Two) for his insurance claim for medical treatment along with interest of 6% Per Annum from the date of filing to till the realization of the amount. The complainant is also do get an award amounting to Rs.40,000/- (Forty Thousands) as compensation for his harassment, mental agony and sufferings which cost due to deficiency in service of the O.Ps and also Rs. 10,000/- (Ten Thousands) as his litigation costs; total decreetal amount of Rs. 1,19,372 (One Lakh Nineteen Thousands Three Hundred Seventy-Two) excluding interest. The O.Ps are liable to pay the said award amount and they are hereby directed to comply this order within 30 days from this day, failing which legal action will be taken against him.
There is no claim against the Pro-forma O.Ps. So the case is dismissed against them.
Let a copy of this final order be sent to the concerned parties through registered post with A/D or by hand forthwith for information and necessary action.
Dictated & Corrected by me
