Dated : 28 July, 2022

Judgement

HON’BLE MR. SUDIP NIYOGI,                                                     PRESIDENT

FACTS

            In a  nutshell, the case  of the complainant is that she is a holder of Health Insurance Policy (Re-Assure) under Max Bupa Health Insurance Company Limited being policy No. 3160299020210 as  [ported from Mediclaim policy under  “The Royal Sundaram General Insurance Company Limited”] and  she has been continuing  with the policy since 2007 by making  payment of premium in a regular manner. She was admitted in  Medica Superspeciality Hospital, Mukundapur Kolkata  on 27.03.2021 for Covid-19 Pneumonia following the advice of the doctor of the same hospital and was discharged   on 02.04.2021 after being treated. At the time of admission she submitted  all necessary documents to the OPs through hospital for  cashless facility. As per her policy,  she is entitled  to that facility. However, the complainant  had to spend Rs.1,40,53 in total for her treatment in the said hospital. Thereafter, on being discharged she applied for reimbursement of her aforesaid medical expenses on 28.04.2021  being No. 658125 dated 02.05.2021 through online but the Insurance Company allowed  only Rs.88,467/- and disallowed Rs.51,586/-. OPs also sent a settlement letter dated 05.07.2021 through email without mentioning the item wise clause of the policy under which the deductions were made. Complainant  asked for the particulars of  such deduction clause wise through email dated 29.06.2021 and 04.07.2021 but till date she  did not receive any reply. Following the demand  of the OPs for break up bill of the hospital complainant  duly submitted the same but OPs did nothing. This apart, the complainant also applied for reimbursement  of Rs.4693.50/-  as expenses for pre-post hospitalization period  but that was also rejected.

  Complainant  alleged deficiency in service  on the part of the  OPs as they, with some ulterior motive intentionally avoided paying reimbursement of the medical expenses which according to the complainant, she  is entitled to. So,  she  filed the instant complaint with  this commission  praying  for an order for reimbursement of the said amount along with compensation and cost of litigation.

 Opposite parties contested the case by filing a written statement and also adducing evidence. They admitted the policy of the complainant and also the claim for reimbursement which was submitted with them. They examined the documents for  reimbursement and made payment of Rs.88,467 only on 28.06.2021.

            They also mentioned about deductions which were made under  different heads. According to OPs, complainant has no cause of action against them and therefore, the  instant complaint is liable to be dismissed.

            On the prayer of the complainant, the petition of complaint was treated as his  evidence. However, opposite party filed their  evidence  on  affidavit. Both parties also exchanged questionnaires. But OP did not file  replies to the questionnaire of the complainant. Both parties also filed brief   notes of  their respective argument.

POINTS FOR DETERMINATION

1. Is the instant case maintainable?
2. Was there any deficiency in service on the part of the OPs as alleged?
3. Is the complainant entitled to the relief as prayed for?

FINDINGS

Point No: - 1

The complainant is found to have filed this case feeling aggrieved as her claim of reimbursement of medical expenses was not fully allowed by the OPs which according to her, she  is  entitled to. Considering the nature of the claim, this case is found to be maintainable.

Point No: - 1 & 2

            These two points are taken up together for the sake of convenience.

It is admitted that the complainant is a policy-holder which was ported  from Royal Sundaram General Insurance Company Ltd. following the portability Rules & Guidelines. It is also admitted that complainant filed a claim with the OPs for reimbursement of her medical expenditure in connection with her treatment in Medica Super-Specialty Hospital where she had been admitted from 27.03.2021 to 02.04.2021 in connection with treatment of her Covid-19 Pneumonia. The said hospitalization was during the policy period. It is found that complainant claimed Rs.1, 40,053/- towards medical expenses at the said hospital, but out of the said amount, OPs allowed only Rs.88, 467/-. An amount of Rs.51, 586/- was disallowed and that was communicated to the complainant by a letter dated 05.07.2021 through e-mail. However, on receipt of the said communication, complainant wanted to know the  clauses of the Policy  under which the same was disallowed by emails dated 29.06.2021 & 04.07.2021 but no replies were given by the OPs.

            This apart, complainant also made  another claim for reimbursement of Rs.4693.50/- for pre-post hospitalization expenses  on 07.07.2021 and that was also rejected by the OPs which was communicated through email dated July 14^th, 2021.

            Now, what we find, OPs paid only, as pointed out above, Rs.88,467/- towards claim of Rs.1,40,053/. On  obtaining the communication of the claim adjudication, complainant wanted to know through emails under what clause or clauses  the deduction of the amount under  different heads of expenditure were made. No reply was given to the complainant in this regard.

          In their written version, evidence or written argument also OPs did not state any reasons specifically for such deduction. We find complainant also filed break up of medicines along with other documents which the OPs denied as found from their documents. But, annexure G which the email communication dated 07/07/2021 reveals the complainant having supplied the document of breakup bill once again. Thus, OPs failed to show any cogent reasons for not  allowing the  claim for reimbursement on different heads. 

        Complainant claimed inter alia, Rs.51,586/- being the balance  amount of her original claim of  1,40,053/-  after payment of Rs.88,467/-.  The break up bills of expenditure reveals the said Rs.1,40,053/- is the aggregate sum of expenditure under different heads of service. Annexure- II, List 1 of the policy specifies  the different items  which are not covered by the policy. We also find under the same head -  some articles are allowable while others are  not and there are articles regarding which there is nothing specific  in the policy whether  they are allowable or not. Regarding this, neither of the parties submitted anything specifically.

        However, the item of food and beverages amounting to Rs.236/- is not allowable. We also find under IP Surgical Disposables several items are not allowed, namely, ounce, thermometer, ECG Electrode etc. On consideration we think, out of claim of Rs.51,586/- a sum of Rs.48,000/- can be allowed. This apart, complainant is also entitled to Rs.4690/- towards pre-post hospitalization expenses from the OPs. Thus, complainant is entitled to Rs.52,690/-  being the aggregate of the said two amount along with interest  @ 7% p.a. from the date of 05.07.2021 which is the date of communication by the OPs about the approval of the part of the claim to the complainant.

        We find a few decisions- ref. (1966) 3 SCR 500 relating to interpretation of document to a contract of insurance, AIR 2000 SC and AIR 2005 SC 286 (wherein it was observed that the terms of the contract have to be construed strictly without altering the nature of the contract as it may affect the interest of parties adversely were cited). We have gone through the said decisions but we do not find in our present case, the complainant can get any benefit therefrom.

                   With this all the points are disposed of.

Hence,                        it is

ORDERED 

            This case be and the same is allowed on contest against the OPs.

That the complainant is entitled to Rs.52,690/- (fifty two thousand six hundred ninety only)  towards her claim for reimbursement along with interest @ 7% p.a. from 05/07/2021 from the OPs  until realization.

            Complainant is to get further Rs.3000/- (three thousand only) with towards cost of litigation from the OPs.

            OPs who are jointly and severally liable, are directed to pay the said amount with 45 days form this order.

            In default, complainant shall be at liberty to realize the same in accordance with law. 

Dictated and corrected by me.