By Sri. Subhagan. A.S, Member:-
This is a Complaint filed under section 35 of the Consumer Protection Act 2019.
2. Facts of the complaint in brief:- The Complainant is a Software Engineer employed in Buck Capability Centre Private Limited. The employer of the Complainant had taken a Group Mediclaim Health Insurance Policy for the benefit of the Complainant’s family and his Mother and Father. The policy was meant for cashless treatment. Things being so, on 06.12.2020 the father of the Complainant fell down on the floor and got serious head injury and consequently he was admitted in Bathery Hospital and from there to Meitra Hospital, Kozhikode. He was diagnosed to be having “Traumatic Brain Injury- Diffuse Head injury”. As such, on the basis of cashless treatment claim policy, the matter was informed to Opposite Party but they had not approved cashless treatment claim. Consequently, as it was during the period of COVID PANDEMIC, the Complainant was caused to suffer financial and mental difficulties. The Complainant’s father was discharged from Meitra Hospital on 21.12.2020. At the time of discharge, the HR Manager of the Opposite Party had offered to admit the claim. Afterwards, the Opposite Party repudiated the claim No.109 178 502 for INR 2,48,631/- of the complainant. The reason pointed out by the Opposite Party for repudiation of the claim was stated as “Is known cause of alcoholism and fall is related to alcoholism either being under influence or withdrawal phase”. The Complainant’s father had not caused any accident as stated by the Opposite Party. No statement was made from the hospital as such. When the father of the Complainant became conscious , had told that he was slipped and fell down on the floor. The Opposite Party wrongly says that the injury was due to alcoholism only for the purpose of repudiating the claim. The act of the Opposite Party has resulted in serious financial, mental and other hardships, loss and injury to the Complainant. The rejection of cashless claim and refusal of reimbursement of the amount of the bill paid by the Complainant in the hospital is deficiency in service on the part of the Opposite Party. Hence this Complaint, with prayers to order the Opposite Party to reimburse the amount of INR 2,48,631 together with interest @ 15% from 02.01.2021, compensation of Rs.75,000/- for financial, mental and other loss, injury and hardships and Rs.25,000/- for cost of this Complaint.
3. Commission registered the Complaint and notice was served on the Opposite Party. Though, the Opposite Party represented in the initial stage, they failed to file version and produce any evidence. So the Opposite Party was set ex-parte.
4. Chief affidavit was filed by the Complainant, documents Exts.A1 to A6 were marked from his side and he was examined as PW1. In oral examination, the Complainant reiterated all his allegations.
5. Commission analised the complaint, chief affidavit of the Complainant, his oral depositions and the documents filed by him. The allegation of the Complainant is that though the Complainant’s father was covered under the insurance policy for cashless treatment on hospitalization, the Opposite Party rejected his claim for cashless treatment as well as reimbursement of the amount of hospital expenses amounting to INR 2,48,631/- on discharge from hospital, stating that “is a known cause of alcoholism and fall is related to either being under influence or withdrawal phase”. The repudiation of the claim is evident from Ext.A4 document marked by the Complainant. In Ext.A2 which is issued by Dr. P.P. Sathianathan of Vinayaka Hospital, Sulthan Bathery, it is stated that the “Patient was not under the influence of alcohol at the time of incident nor admission”. The certificate marked as Ext.A5 issued by Dr. Mishal Johny of Meitra Hospital also states that “ He was not under the influence of alcohol during admission”. So we undoubtedly observe that the claim of the Complainant is repudiated by the Opposite Party finding unsustaining and imaginary observations without any basis. This is clear evidence of deficiency in service for escaping from payment of eligible claim of the Complainant. Here the Opposite Party has not acted in good faith but in an evil motive to disallow the claim
of the Complainant. Therefore, there has been deficiency in service/ unfair trade practice from the part of the Opposite Party. Hence, the Complainant is entitled to get reimbursement of his claim of Rs.2,48,631/- compensation and cost. The cost prayed for is seen exorbitant and he is eligible for a reasonable cost of Rs.10,000/-.
In the result, the Complaint is partly allowed and the Opposite Party is ordered to
- Reimburse Rs.2,48,631/- (Rupees Two lakh Forty Eight thousand Six hundred and Thirty One only) being the claim amount together with interest @ 8% per annum with effect from 06.02.2021, the date of rejection of the claim in respect of the Group Mediclaim Insurance Policy No.51-20-00473-00-00.
- Pay Rs.75,000/- (Rupees Seventy Five thousand only) as compensation and
- Pay Rs.10,000/- (Rupees Ten thousand only) as cost of the Complaint.
The above amounts shall be paid to the Complainant within one month from
the date of this order, failing which the amount will carry interest @ of 8% 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 31st day of August 2022.
Date of filing:08.04.2021.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the complainant:
PW1. Jiji Thomas. Complainant.
Witness for the Opposite Party:
Nil.
Exhibits for the complainant:
A1. Copy of Discharge Summary.
A2. Copy of Treatment Details.
A3. Copy of Letter. dt:06.02.2021.
A4. Copy of Letter.
A5. To Whomsoever it may concern. dt:30.01.2021.
A6. Inpatient Bill (Summary).
Exhibits for the Opposite Party:
Nil.
