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

DATED 10^th DAY OF AUGUST 2023

ORDER

SMT. SUMA ANILKUMAR, MEMBER

The complainant has filed this complaint U/s 35 of Consumer Protection Act 2019, against OP for the following reliefs:-

A) Order directing the OP to pay the complainant a sum of Rs.3,60,677/- with interest at the rate of 14% per annum from the date of claim till date of payment.

B) Order directing the OP to pay to the complainant a sum of Rs.5,00,000/- as damages with interest at the rate of 24% p.a from the date of the complainant till date of payment.

C) Order directing the OP to pay the complainant the cost of this complaint in the interest of justice and equality.

2. Brief facts of this case are as follows:-

The complainant had got infected with Covid-19 in the month of May 2021 and subsequently hospitalized as her oxygen level had dropped below 90-85. During the pandemic period the hospitals were allotted as per the BBMP allotment of the hospital, accordingly the complainant was allotted hospital and got admitted to Sri Krishna Hospital at Magadi Road, Bangalore on 05.05.2021. As per the BBMP help lines allotment made due to medical emergency of reduction in oxygen level, she was in immediate need of treatment. Hence, the complainant was treated in the above said hospital till 13.05.2021 and their discharged from the hospital. The incurred medical expenses was up to Rs.3,60,677/- for which the complainant paid the entire bill amount of the hospital and got discharged on the same day. Further the complainant filed the claim to Star Health Insurance company for claiming the hospitalization bill as per the claim reimbursement procedure for Star comprehensive health insurance policy. The complainant submitted all original bills and claim documents along with duly filed and signed claim form to OP on 10.06.2021.

3. The complainant was shocked that the 2^nd OP sent letter regarding repudiation of claim dated 06.08.2021 vide claims intimation No.CH/2022/141133/2692672 stating that the OP is unable to pay complainant’s claim under the above policy as she was admitted and treated in an excluded provider hospital which was not within the knowledge of the complainant, since the same was allotted by help line. The complainant submits that the OP repudiates the above health insurance policy for the purpose of escaping from their liability to settle the said claims. Hence this complaint filed by the complainant.

4. On issue of notice to the OP’s, OP No.1&2 filed version on 04.02.2023.

5. In the version of the OP’s, the OP’s admitted to the fact that the complainant has availed Star comprehensive insurance policy through Branch office, Malleshwaram, covering Mrs. Manjula and her family members for the floater sum insurance of RS.5,00,000/-. The complainant took vide policy No.P/141133/01/2021/008329 for the period from 31.10.2020 to 30.10.2021. The complainant reported claim in the year of the medical insurance policy vide claim No.CIR/2022/141133/2692672. The complainant was admitted on 06.05.2021 at Krishna Hospital and discharged on 13.05.2021, was treated for Covid-19 Pneumonia, T2DM. The OP submits that on perusal of the claimed documents, the OP observed from the medical records that the insured patient was admitted and treated in and excluded provider hospital as per exclusion No.(11), excluded providers – excl11 of the above policy. The expenses incurred towards the treatment in any hospital or by any medical practioner or any other provider specially included by the insurer and discloses in its website/notification to the policy holders are not admissible. However in case of life threatening situations following an accident, expenses up to the stage of stabilization are payable but not the complete claim. Therefore the OP is unable to settle the claim made by the insured under the above policy. Therefore OP repudiates the claim and the same was intimidated to the complainants, vide letter dated 06.08.2021.

6. The insured on quests made by her through E-mail to the repudiated letter dated 06.08.2021 seeking for reconsideration of claim. The OP again as per medical records submitted by the complainant, re-examined the claim records and submitted final bill date of admission on 05.05.2021, but as per documents and details available to the OP, date of admission is mentioned as 06.05.2021 with claims/paid amount Rs.2,64,950/- submitted by complainant. Hence, the complaint to be dismissed.

7. The complainant filed affidavit evidence along with 7 documents marked as Ex.P.1 to Ex.P.7 and OP’s have filed their affidavit evidence along with 13 documents marked as Ex.R.1 to Ex.R.13. Heard arguments of both the parties.

 8.  On the basis of above pleadings for our consideration are as follows:-

i) Whether the complainant has proved the deficiency of service on the part of OP’s?

ii) Whether complainant is entitled for the relief?

iii) What order?

8.  Our answers to the above points are as follows:-

Point No.1:- affirmative.

Point No.2:- Partly affirmative.

Point No.3:- As per the final order.            

REASONS

9. Point No.1&2:- These two points are interrelated and hence they are taken up for common discussion.

10. It is clear by the document Ex.P.1 submitted by the complainants, that the complainant has taken insurance policy from Star Health and allied Insurance Company Limited for Rs.5,00,000/- from 31.10.2020 to mid night of 30.10.2021. OP also admits to the facts that the complainant has taken insurance policy from them for Rs.5,00,000/- and also that the complainant has taken treatment for Covid-19 Pneumonia and T2DM in Sri Krishna Hospital, Magadi road. The Ex.R.8 and Ex.P.5 clearly shows the date as 06.05.2021 prescribed by Sri Krishna Hospital. The complainant had to get the treatment for Covid-19 Pneumonia and T2DM in Sri Krishna Hospital as per the BBMP helpline as she was in immediate need of treatment due to the reduction in oxygen levels. The complainant was admitted on 06.05.2021 which is well within the time period of the Insurance Policy. The complainant had to take the help of BBMP helpline as it was a medical emergency, and matter of life and death of the patient/complainant. Therefore, it being the period of Covid-19, the complainant could not admit herself in the referred hospital of the insurance company.

10.     Further the OP mentions in the Ex.P.1, policy dated 16^th October 2020, policy No. P/141133/01/2021/008329 that “In case of need for hospitalization kindly prefer our network hospital (list is available in our network) for quick response to your claim request”. The OPs clearly asks the complainant to prefer the hospitals mentioned by them. The word “prefer” meaning according to the dictionary is “to highlight choose something rather than something ease, to like something better”. This shows that the complainant is given choice to choose the hospital as the OP have mentioned to prefer and not compulsorily or mandatorily admit to the hospitals mentioned by them. Therefore considering the above facts, Covid-19 situation and medical emergency treatment undergone by complainant, the OP is under deficiency of service and unfair trade practice. Hence, we answer Point No.1 in affirmative and Point No.2 in partly affirmative.  

11. Point No.3:- We direct the OP to refund the amount of Rs.3,60,677/- with interest of 10% from date of order and sum of Rs.20,000/- towards the compensation and Rs.10,000/- towards legal expenses. In view of the above discussion referred, we proceed to pass the following order:-

ORDER

i) The complaint filed by the complainant against OP is hereby, allowed in part.

ii) The OP is directed to pay the amount of Rs.3,60,677/- with interest of 10% the date of order till realization.

iii) OP is directed to pay Rs.20,000/-  towards compensation and Rs.10,000/- towards the litigation cost.

iv) The OP is directed to pay entire amount within 60 days from the date of this order, if failed will carry interest of 12% on Rs.3,60,677/- after expiry of 60 days till realization.

v) Furnish the copies to both the parties. No cost.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 10^th day of AUGUST, 2023)

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

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