SMT.MOLYKUTTY MATHEW : MEMBER
This is a complaint filed by the complainant U/S 35 of the Consumer Protection Act 2019 for an order directing the OP to pay the balance claim amount of Rs.9065/-to the complainant along with Rs.20,000/- as damages caused to the complainant for the deficiency of service and unfair trade practice on the part of OP.
The brief of the complaint :
The complainant is working as an Advocate in Thalassery court and he is an account holder of South Indian Bank Ltd,Kannur . The South Indian Bank Ltd,Kannur acted as an agent for the business of OP regarding Corona Kavach policy introduced by the OP. As such the manager of the bank contacted the complainant explained and promoted the benefit of corona kavach policy during the pandemic period of covid-19. As such the complainant availed a policy of corona kavach in the year 2020 and subsequently the policy was renewed for the period from 10/8/2021 to 21/5/2022 the policy bearing No.76080034218700000017. The effective policy period shown in the policy is 25/8/2021 to 21/5/2022. The premium paid by the complainant is Rs.13,794/-. The sum assured as per the policy is Rs.50,000/- to 5,00,000/-. The medical expenses of hospitalization for covid-19 for a minimum period of 24 hours shall be admissible for the coverage. The agent of the company explained that the coverage includes the total expenses which will incur for the covid treatment . The complainant due to the complaint of fever and wheeze rush to the laboratory for testing covid-19 on 16/9/2021 and the report was positive. On 17/9/2021 at about 8.10 P.M the complainant was admitted in Aster Mims Hospital ,Kannur evaluated in emergency department. ECG,X-ray and blood investigations are done from the hospital and doctor who attend the complainant advised for cocktail antibody injection as a method of preventing the complications of covid disease. The approximate amount for the medicine as explained by the doctor is more than Rs.1,50,000/-. Then the complainant requested the doctor to discharge him on the same day at 10’o clock. The complainant paid an amount of Rs.3484.83/- as expenses for his treatment and testing at Aster Mims hospital Kannur. Then on the next day 18/9/2021 the complainant was taken to AKG Memorial Hospital,Kannur and he was admitted in covid ward. From there also he was advised to take antibody cocktail injection. But the medicine is not in stock at AKG hospital at that time. Then the complainant was shifted to Thalassery Govt. Hospital for taking antibody cocktail injection. Then after 2 hour observation again the complainant was taken to AKG hospital for further observation and treatment. Then the complainant was discharged from the hospital on 20/9/2021 and he paid Rs.8620/- as the hospital bill and Rs.500/- as canteen food expenses. The complainant submitted a claim for treatment expenses at MIMS hospital as KOC1021CL000246 and the claim KOC 1021-CL-0002465 the treatment expenses of AKG Hospital before the OP. But on 26/11/2021 the complainant received Rs.928/- has been disbursed against the claim KOC1021 CL0002467 and Rs.2670/- disbursed against the claim KOC 1021-CL-0002465, the total claim of the complainant is Rs.12,663/-. But the complainant obtained only Rs.3598/- from the OP. The complainant is entitled to get the balance amount is Rs.9065/- . As per the Corona Kavach policy the complainant is entitled to get the amount in the entire bill re-imbursed which includes the medicine as well as consumable items used for the treatment of the corona patient. So the act of OP, the complainant caused much mental agony and financial loss. So there is deficiency of service and unfair trade practice on the part of OP. Hence the complaint.
After receiving notice the OP appeared before the commission and filed his written version. The OP contended that M/s Vidal Health is the 3rd party licensed by IRDA to process health insurance claims arising out of medi claim policies issued by the OP. The claims are process strictly abiding by the terms and conditions stipulated in the policy. This OP had disbursed an amount of Rs.3598/- to the complainant and had settled the claim. The said amount is the maximum amount payable to the complainant under the policy applying the sub limits as per policy and also deducting non-admissible heads. There is no deficiency in service and unfair trade practice on the part of OP So the complaint may be dismissed.
On the basis of the rival contentions by the pleadings the following issues were framed for consideration.
- Whether there is any deficiency of service on the part of the opposite party?
- Whether the complainant is entitled for any relief?
- Relief and cost.
The evidence consists of the oral testimony of PW1 and Exts. A1 to A10 were marked. On OP’s side DW1 was examined and Exts.B1&B2(series) marked.
Issue No.1:
The Complainant had adduced evidence before the commission by submitting his chief affidavit in lieu of his chief examination to the tune of the pleadings in the complaint and denying the contentions in the version. He was cross examined as PW1 . According to the complainant Exts.A1 to A10 were marked on his part to substantiate his case. Ext.A1 is the policy issued by OP. Ext.A2 is the discharge summary of Aster Mims and the discharge at request, RTPCR came to be positive on 17/9/2021. Ext.A3 is the cash bill of Aster Mims for an amount of Rs.3464/-. Ext.A4 is the OP record of Government General Hospital Thalassery. Ext.A5 is discharge summary from AKG Hospital dtd.20/9/2021. Ext.A6 is the discharge bill of AKG hospital, Et.A7 is the medical bills dtd.19/9/2021. Ext.A8 is the canteen bills dtd.21/9/2021. Ext.A9 is the policy clause. According to the complainant he is the policy holder of OP. In the evidence of DW1 who states that Table of benefits ആണ് clause-12 ൽ പറഞ്ഞിരിക്കുന്നത്? അതെ.(1) hospitalization expenses(2) pre-hospitalization expenses and (3) post hospitalization expense എല്ലാത്തിനും coverage ഉണ്ട്? ഉണ്ട്. Complainant claim പ്രകാരം hospitalization expense ഉം pre-hospitalization നുമാണ് ആവശ്യപ്പെട്ടത്? അതെ. Home care treatment expense complainant claim ചെയ്തിട്ടില്ല? ഇല്ല. As per the corona kavach policy the complainant is entitled to get the claim amount of Rs.12,663/-. But the complainant is only received Rs.3598/- from the OP. The complainant is entitled to get the balance amount of Rs.9065/-. But the OP fails to do so. So we hold that there is deficiency of service and unfair trade practice on the part of OP. Hence the issue No.1 is found in favour of the complainant and answered accordingly.
Issue No.2&3:
As discussed above the complainant is the policy holder of OP. The OP has provided hospitalization expenses , pre-hospitalization and post hospitalization expenses. The total claim of the complainant is Rs.12663/-. The complainant obtained only Rs.3598/-. The complainant is entitled to get the balance amount of Rs.9065/-. So, we hold that the OP is directly bound to redressal the grievance caused to the complainant. So the complainant is entitled to get Rs.9065/- from the OP as the balance amount the amount along with Rs.10000/ as compensation for mental agony caused to the complainant and Rs.5000/- as litigation cost. Thus issue No.2&3 are also accordingly answered.
In the result the complaint is allowed in part directing the opposite party to pay the balance amount of Rs.9065/- to the complainant along with Rs.10000/- as compensation for mental agony caused to the complainant and Rs.5000/- as litigation cost within 30 days of receipt of this order. In default the amount of Rs.9065/- carries 9% interest per annum from the date of order till realization. Failing which, the complainant is at liberty to execute the order as per the provisions of Consumer Protection Act 2019.
Exts:
A1- Insurance policy
A2-Discharge summary
A3-Cash bill dtd.18/9/2021
A4- Prescription from Thalassery Govt. hospital dtd.18/9/21
A5- Discharge summary from
AKG hospital dtd.20/9/2021
A6- Discharge bill
A7- Medical bills dtd.19/9/21
A8- Canteen bill dtd.21/9/21
A9- policy clauses
A10- letter issued by TPA dtd.14/11/21
B1- Attested copy of policy
B2(series)- calculation statement(2 in Nos)
PW1- M.V.Rajendran- complainant
DW1-Haridasan.K.-OP
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
eva
/Forwarded by Order/
ASSISTANT REGISTRAR
