By Sri. A.S. Subhagan,  Member:

          This is a complaint preferred under Section 12 of the Consumer Protection Act 1986.

          2. Facts of the complaint in brief:-  The Complainant is an insurance policy holder of the Opposite Parties having policy No.P/181315/01/2018/002468.  The Complainant  had insurance with the Opposite Party with effect from 04.11.2015.  Owing to illness,  on 14.03.2018,  the  Complainant consulted Dr. Manoj of WIMS Hospital,  Meppadi and he was admitted there on 15.03.2018 for endoscopy, CT Scan etc for  diagnosis.  On seeing stone in his gall bladder, the Complainant was discharged  from  WIMS Hospital  and admitted in MIMS Hospital,  Kozhikode on 17.03.2018 for better treatment.  The Complainant was in-patient there upto 23.03.2018  and  done treatment including surgery.   For  treatment in the above two hospitals, the Complainant had to incur  expenses and caused  loss and injury.  Hence,  as per claim intimation number CI/2018/181315/0656759,  the Complainant had submitted claim application with all  the relevant documents to the Opposite Parties.  In addition,  the originals of medicine bills,  treatment check-up,  test bills and all other cash bills were submitted to the Opposite Parties.  The total expenses for treatment of the  Complainant came to Rs.1,82,350/-.  But the  Opposite Parties repudiated the claim which has caused mental agony, loss and injury etc to the Complainant.  Hence this complaint  with prayers

1.  To direct the Opposite Parties to pay Rs.1,82,350/-   with 12% interest if they fail to pay the amount.
2. To direct the Opposite Parties to pay Rs.50,000/-  as  compensation for mental agony, loss and injury.
3. To direct the Opposite Parties to pay Rs.10,000/-  as cost of this  complaint and
4. To grant any other relief  which the Commission deems fit enough to grant.

3.  Notices were served upon the  Opposite Parties for appearance.   They

appeared before the Commission and joint version  was filed.

4. Contents of version :- The averments in paragraphs 1 to 5 of  the complaint being not fully correct and hence denied.  It is submitted that the Complainant has taken policy of Medi Classic Health Insurance Policy from the Opposite Parties for the period  commencing from 04.11.2015 to 03.11.2016 for a sum  insured of Rs.2,00,000/- and the  same has been renewed upto  3/11/2018 vide policy Number: P/181315/01/2018/ 002468. At the time of availing the policy,  the complainant was supplied with the Terms and Conditions of the policy. The terms and conditions of the Policy were explained to the petitioners at the time of proposing policy and the same was served to them along with the Policy Schedule. Moreover, it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED".

5. The Complainant has registered two claims under this policy.  In claim Number CLI/2018/181315/0650962, the Opposite Parties have received a pre-authorization request for cashless treatment from DM WIMS, Wayanad stating that the Complainant was admitted at the hospital on 15/03/2018 and provisionally' diagnosed with Periampullary Diverticulum Obstructive Jaundice. On receiving the pre-authorization, the Opposite Parties had forwarded a query dated 15/03/2018 to the hospital and requested to forwarded the following documents :-

     1. Detailed initial assessment Sheet.

     2. Exact duration of present ailment.

     3. Any previous history of similar episodes

     4. All investigation reports along with LFT"

6. Based on the query letter, the hospital authority forwarded the Upper GI Endoscopy Report dated 15/03/2018 which shows in the Indication column that If K/C/O Periampullary diverticulum with Jaundice and impression that “Hiatus Hernia, Barrett's Esophagitis, Fundal Polyps, Periampullary Diverticulum”.  After that the Opposite Parties had again requested the Copy consultation when Periampullary diverticulitis was first diagnosed. But the Opposite Parties did not get any sufficient records from the Hospital Authority. Since the Opposite Parties could not decide the admissibility of the claim, the Opposite Parties denied the cashless facility and the same was informed the Hospital Authority and the Complainant on 17/03/2018.  After discharged from hospital, the Complainant had submitted claim form along with discharge summary, bills and reports to the Opposite Parties. In second claim Number CLI/2018/181315/0656759, It is submitted that the complainant was admitted on 17/03/2018 at Aster MIMS Hospital, Calicut for the treatment of Cholelithiasis with choledochothiasis and after the treatment he was discharged on 23/03/2018 and submitted claim form along with discharge summary, bills and reports to the Opposite Parties.  The discharge summary dated 17 /03/2018, issued by the Aster MIMS Hospital Calicut, reveals that the Complainant had taken UGI Scopy( Outside)- Periampullary diverticulum with food lodged and barret Oesophagus. After receiving the claim documents the Opposite Party forwarded a query letter dated 14/06/2018 to the Complainant and requested to forward the following documents for processing the claim:-

a. Letter from treating doctor- Provide exact duration for Periampullary    

    Diverticulum.

b.  Submit all past consolation paper, Lab reports, discharge summary when

     periampullary diverticulum diagnosed first time.

c.  Patient had history of abdominal pain last 2 months- Submit all the past

    consultation papers, lab reports at that time.

7. Based on the Query letter, the Complainant had submitted the treating Doctor Certificate (Dr. Manoj. M.G) and stated that the Complainant was diagnosed with Periampullary Diverticulum on Feburary 2016 and did not provide the scan reports and other details. On the basis, the Opposite Parties had again advised to submit (1) “All the consultation papers, lab reports (USG abdomen, UGI scopy report), prescription papers when periampullary diverticulum first time diagnosed. (2) Patient had history of abdominal pain last 2 months ­ Submit all the past consultation papers, lab reports for last 2 months”.   But the Complainant has not provided the details of the Opposite Parties for the above mentioned records. Since the Opposite Parties were not able to decide the admissibility of the claim, sent a rejection letter to the Complainant on 27/09/2018.   The allegations in the original petition are admitted only to the extent stated supra and the remaining is denied.   The petitioner has filed this complaint vexatiously and frivolously for the sole purpose of harassing the Opposite Parties with the intention for getting unlawful enrichment from the Opposite Parties who are dealing with public money and functioning under the guidelines of IRDA controlled by the Government of India. As public money is held in trust, the company must exercise abundant caution in dealing with the claims by applying all conditions correctly. It is respectfully submitted that there has been no deficiency of service, any type of damages, mental agony from the part of the Opposite Parties. The Opposite Parties had acted only as per the terms and conditions of the policy. The Complainant has absolutely no cause of action for the petition and not entitled for compensation.

8. Proof affidavit was filed by the Complainant,  Exts.A1 to A9 and Ext.X1

series were marked from his side and he was examined as PW1.  Proof affidavit was also filed  by Balu. M,  Assistant Manager –Legal for the Opposite Parties,  Exts.B1 to B7 were marked from the side of the Opposite Parties,  he was examined as OPW1 and the complaint was finally heard on 06.01.2023.

          9. Considering the Complaint, version,   proof affidavits,  documents marked, oral depositions of the parties and the arguments of the counsels of  both the Complainant and the Opposite Parties, we raised the following points for consideration.

1.  Whether there has been deficiency in service/unfair trade practice from the side of the Opposite parties?
2. If so,  whether there the Complainant is entitled for compensation and cost of the complaint and  what shall be the amount of compensation and cost?

10.  Point No.1:-  The case of the Complainant is that being a policy holder of the Opposite Parties,  though the Complainant had submitted insurance policy claim application together with all relevant records and documents,  the Opposite Parties repudiated the claim. The Opposite Parties had admitted that the Complainant had taken a Medi classic Health Insurance Policy from  the Opposite Parties for the period  from 04.11.2015 to 03.11.2016 for a sum of Rs.2,00,000/-  and the same had been renewed upto 03.11.2018.   It is the  fact that on 15.03.2018 the Complainant was admitted in WIMS Hospital,  Meppadi  and from there discharged on 17.03.2018  and admitted in MIMS Hospital Kozhikode for better treatment.  It is admitted by the Opposite  Parties that  a pre-authorisation request for cashless treatment from DM WIMS,  Wayanad and on receipt of which the Opposite Parties sought for some more documents such as detailed initial assessment sheet,  Exact duration of present ailment,  any previous history of  similar  episodes,  all investigation reports along with LFT  etc.  Based on the query,  the  hospital authority forwarded the Upper GI Endoscopy Report dated 15.03.2018 which showed  the indication column that “K/C/O periampullary   diverticulam with jaundice and impression that” Hiatus Hernia,  Barrett’s Esophagitis,  Fundal Polyps,  periampullary Diverticulum” etc.  After that the Opposite Parties had again requested the copy of consultation when periampullary diverticulitis was  first diagnosed.  But as the Opposite Parties did not get sufficient records from the hospital, the Opposite Parties could not decide the admissibility of the claim and hence the cashless facility was denied.  It is seen admitted by the  Opposite Parties that the  Complainant had  then submitted claim form along with discharge summary, bills and reports to the Opposite Parties.  After receiving the claim documents, the Opposite Party forwarded a query letter dated 14.06.2018 to the Complainant and requested to forward letter from treating doctor stating exact duration for periampullary Diverticulam,  all post consultation  paper,  lab reports, discharge summary when periampullary diverticulam diagnosed first time,  all the past consultation papers, lab reports at the time of history of abdominal pain for last two months etc.  Based on the query, the Complainant had submitted the treated Doctor’s  Certificate and stated that the  Complainant was diagnosed with periampullary Diverticulum  in February 2016 but did not provide other  reports and hence as the Opposite Party could not decide the admissibility of the claim and therefore,  they repudiated the claim on 27.09.2018.  From the facts,  documents, oral evidences and  the circumstances of the case, we observe that

1. The Complainant had a valid  Health Insurance Policy  at the time of   hospitalization and treatment.
2. The Complainant was seen admitted  in DM WIMS on 15.03.2018 and discharged from there on 17.03.2018 which are evident from Ext. A6 discharge summary.
3. The Complainant is seen  admitted in Aster MIMS on 17.03.2018 and discharged from there on 23.03.2018 which are evident from Ext.A7 discharge summary.
4. Though cashless pre-authorisation claim was submitted,  it was denied by the Opposite Parties on 17.03.2018.
5. Afterwards insurance claim application was submitted together with discharge summary, bills and reports to the Opposite Parties.
6. The Insurance claim was also repudiated by the Opposite Parties on want of some more  additional records  from the hospital.
7. The claim of the Complainant is admittedly repudiated by the Opposite Party on 27.09.2018 which is about after six months of his treatment and discharge from Aster MIMS Hospital and MIMS Hospital.
8. The Complainant has submitted in his complaint that all the required  documents, records  and bills had been submitted to the Opposite Parties along  with the insurance claim application form.
9. The Complainant has reiterated these facts, as noted as  number ‘8’ above in his chief affidavit also.
10.  In  cross examination of PW1,  the Complainant was asked “(Q)  Hcp claim process sN¿m³ Bh-i-y-ap-ff tcJ-IÄ \n§Ä sImSp-¡m-Xn-cp-¶-Xn-\m-emWv  claim repudiate   sNbvXp F¶v ]d-ªm icn-bm-tWm? (A) B tcJ-IÄ Fsâ ssIhiw CÃm-bn-cp-¶p.
11.  In re-examination of PW1,  the Complainant has stated that “F\n¡v In«nb FÃm tcJ-Ifpw FXnÀ I£n Øm]-\-¯n sImSp-¯n-cp-¶p”.
12. In  cross examination of  OPW1, he has stated that “ Policy bpsS terms and conditions  ]cm-Xn-¡m-cs\ t_m[-y-s¸-Sp-¯n-b-Xn\v  tcJ-IÄ CÃ.   Premium FSp-¯-Xn\v tijw  Policy terms and conditions Ab-¨p-sIm-Sp-¡m-dp-­v.  t\cn«pw sImSp-¡m-dp-­v.  Ch In«n-b-Xn\v ]cm-Xn-¡m-csâ I¿n \n¶pw H¸v hm§n-¨n-cp-¶pthm F¶v Adn-bn-W-sa-¦n tcJ-IÄ ]cn-tim-[n-¡Ww”. “F´p Imc-W-¯m-emWv ]cm-Xn-¡m-csâ  reimbursement claim    Dw  repudiate  sNbvXv non-submission of documents F¶ ImcWw ]d-ªm-Wv.  GXv clause {]Im-c-amWv claim repudiate sNbvXXv F¶v ]d-ªn-«nÔ.

11.  Indemnity and utmost  good faith are the essential  basic principles of the

contract  of  insurance.  Here,  in this case, the Complainant who is a senior citizen is struggling from March 2018 onwards for the  mercy of the Opposite Parties for settlement of his grievance.  The Complainant or  whoever may be at his place shall not be in a position to produce any document which  is not  available under his custody.  The Complainant has averred  that he has submitted all the documents,  bills and reports to the Opposite Party along with the claim application.  The treated hospital also could not produce the additional documents sought by the Opposite Party.  Asking to produce documents beyond the  control of the Complainant and repudiating the claim more than after about  six months of treatment and discharge from the hospital, inspite of having a valid insurance policy, can no way be  admitted  by the Commission.  Insurance is not only a business but also a service to be provided to the policy holders in needy time.  Usually  health insurance policies are taken by ordinary general public like the Complainant to meet  their financial needs at the time of unexpected contingencies arising from their health problems leading to hospitalization and treatment.   Hearing repudiation of their valid claim in a valid  policy will adversely affect their financial stability,  result in monetary loss and expenses and ultimately result in their severe mental agony.  During the period of validity of the insurance policy of the Complainant,  in this present case, the Opposite  Parties denied cashless treatment benefit and also reimbursement of claim amount,  demanding more and more documents which are not under the control of the Complainant, without specifying as per which clause of the policy conditions the additional documents are sought,  is not seen in good faith, but in bad faith with an evil motive to deny eligible, reasonable and speedy disbursement of the claim to the Complainant, for unjustifiable enrichment of money of the Complainant  which is nothing but deficiency in service/unfair trade practice from the part of the Opposite Parties leading to the  violation of the principles of natural  justice.  The Opposite Party has repudiated the claim of the Complainant without any valid reasons and without specifying  the policy condition under which it is denied.   All  other  contentions of the  Opposite Parties are immaterial, not able to be considered and hence discarded.  Therefore, point No.1  is proved in favour of the Complainant.

          12.  Point No.2:- As point No.1 is proved in favour of the Complainant,  he is entitled to get reimbursement of his claim amount which is not disputed by the Opposite Parties, compensation and cost of the complaint etc.  But the compensation claimed  by the Complainant is seen exorbitant.  Actually in our view, the Complainant has a right to get compensation of Rs.30,000/-.

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

1.  Pay Rs.1,82,350/-  (Rupees One Lakh Eighty Two thousand Three hundred and Fifty only)  being the amount of insurance claim which is not disputed by the Opposite Parties.
2. Pay Rs.30,000/-  (Rupees Thirty thousand only) as compensation and
3. Pay Rs.10,000/-  (Rupees Ten thousand only) as cost of this complaint.

The above amounts shall be paid to the Complainant,  jointly and severally

by the  Opposite Parties within  one month from the date of this order,  failing which the above amounts will carry interest @ 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 Commission on this the 20^th  day of January 2023.        

Dated of filing:02.11.2018.

                                                                    PRESIDENT (I/C)         :  Sd/- 

                                                                   MEMBER                    :  Sd/- 

APPENDIX.

Witness for the complainant:

PW1.          Babu Rajendranath. T.G.                   Complainant.                 

Witness for the Opposite Parties:

OPW1.        Balu. M.                                  Assistant Manager- Legal.        

Exhibits for the complainant:

A1.       Mediclassic  Insurance Policy (Individual).

A2.       Advance Premium Receipt.  

A3.      Prescription.                                    dt:14.03.2018.

A4.    Copy of  Certificate.

A5.    Copy of  Prescription.                       dt:14.03.2018.

A6.    Coy of Discharge Summary.

A7.    Copy of Discharge Summary.

A8.    Cash Receipt.                                    dt:17.03.2018.

A9.    Copy of Discharge Bill.                    dt:23.03.2018.     

X1 series    Medical Bills, and Discharge  Summary.      

Exhibits for the Opposite Parties:

B1.    Copy of Pre- Authorisation Request Form.

B2.    Copy of Letter.                                                     dt:15.03.2018.

B3.    Copy of Upper GI Endoscopy Report.                 dt:15.03.2018.

B4.    Copy of Letter.                                                     dt:17.03.2018.

B5.    Copy of Letter.                                                     dt:14.06.2018.

B6.    Copy of Discharge Summary.                              

B7.    Copy of Letter.                                                      dt:27.09.2018.

                                                                                    PRESIDENT (I/C):  Sd/-        

                                                                   MEMBER            :  Sd/-