Dated : 28 July, 2022

Judgement

HON’BLE MR. SUDIP NIYOGI,                                                PRESIDENT

FACTS

            The case of the complainant in short is that he had been suffering from “Covid-19 Pneumonia” and on 27.03.2021 he got admitted to Medica Super-specialty Hospital for treatment, Mukundapur, E.M. Bypass, Kolkata, following the advice of the doctor of the same hospital and was discharged on 07.04.2021. He had to spend a sum of Rs.2,93,606/-in total towards medical expenses on his treatment in the said hospital. On 02.05.2021, he submitted a claim for re-imbursement of the said amount of medical expenses being claim No. 660224 dated 06.05.2021 with the OPs through online.

 The complainant claimed to be a holder of Health Insurance Policy (Re-Assure under Max Bupa Health Insurance Company Limited) being policy NO. 31602990202100 [ported from Mediclaim Policy under “The Royal Sundaram General Insurance Company Limited and he has been continuing his policy since 2007 by paying the amount of premium in a regular manner.

On June 15 and 28, 2021, the opposite party asked for some documents through emails for consideration of his claim though the said  documents already were sent, as claimed  by the complainant. However, he again sent the documents through emails. There were several correspondences between them but the OPs sent a settlement letter dated 05.07.2021 to the complainant declining the claim, in question, on the reason of non-submission of necessary papers. The request of the complainant for reconsideration of his claim which he considered to be legitimate was also denied on 14.07.2021 by the OPs. The complainant also claimed to have paid Rs.6762.50/- only for pre-post hospitalization expenses and he is also entitled to the said amount.

It is alleged by the complainant that with some ulterior motive the OPs avoided discharging their duties in making payment to him and their acts thereby amounted to deficiency   in service on their part.  So, he was compelled to file the present complaint with this commission praying for several reliefs including cost of litigation as stated in the petition of complaint.

Opposite parties contested the case by filing a written version along with evidence and documents etc. wherein they admitted  the policy of the complainant and also the claim for re-imbursement from them in connection with his treatment for Covid-19 at the said hospital. They also required the complainant to file further documents and thereafter on consideration repudiated his claim not being satisfied with the documents and communicated to the complainant by email ID.

            The petition of complaint, on the prayer of the complainant, was treated as his evidence-in-chief. OPs filed their evidence on affidavit. They also exchanged questionnaires but OPs did not file any replies to the questionnaire of the complainant.  

            Now the points for determination are as follows:-

1. Whether the instant case is maintainable?
2. Whether there was deficiency in service on the part of the OPs as alleged?
3. Whether the complainant is entitled to the relief(s) as prayed for?

FINDINGS

Point No. 1     

This case is found to have been filed by the complainant against the opposite parties alleging deficiency in service. According to complainant, he was a policy-holder and he incurred medical expenses for  treatment of his ailment but subsequently when he claimed for re-imbursement of such expenses as per terms of the policy, the OPs rejected his claim. Feeling aggrieved, he filed the instant case.

Having heard the submissions on both the parties and also going through the materials we think, the complainant has a veritable ground to approach this Commission for redressal of his grievances. Therefore, the instant case is found to be maintainable.

Points No. 2 & 3.

Both these two points are taken up for together discussion for convenience.                                                            

            We have carefully gone through the materials on record including evidence of the parties and the documents. Also gone through the questionnaires exchanged between the parties. Be it noted here that complainant submitted replies to the questionnaires of the OPs. But no replies to the questionnaire of the complainant was filed on behalf of the OPs. We have also considered the contentions of the parties as contained in their respective written arguments.

            It is admitted by the OPs that the complainant is the holder of health insurance policy (Re-Assure) under Max Bupa Health Insurance Company Limited fide policy No. 31602990202100 which was ported from mediclaim policy under the Royal Sundaram General Insurance Company Limited.  The said policy was for one year with the  date of commencement of policy as 21.03.2021 and the date of expiry as  20.03.2022 and the base sum insured Rs.10,00,000/-.

            Admittedly, complainant made a claim for re-imbursement of his medical expenditure with the OPs in accordance with the terms and conditions of the  insurance policy. He also filed relevant documents with his claim application.

            According to complainant, he was admitted to Medica Superspeciality Hospital Kolkata, on 27.03.2021 for Covid-19 Pneumonia following  the advice of the doctor of the said hospital and was discharged on 07.04.2021 and  he had to spend Rs.2,93,606/- for his treatment in the said hospital.

            We also find, subsequently OPs demanded several other documents, namely, hospital bills with break up and medical certificate/papers relating to the ailments of  hypertension, hypothyroidism etc. of the complainant which he claimed to have filed with them.

In spite of that the claim of the complainant was repudiated by the OPs on the ground as stated by them – “non-submission of mandatory claim documents - in absence of proper query reply for repeated reminders, the authenticity and accomplishment of documents for claim procedure not established. Hence, claim cannot be paid” under 7.3 of the agreement.

            So, we find the grounds for rejection of the claimant as shown by the OPs are           

1. Non-submission of mandatory claim documents.
2. Failure of the complainant to give proper replies to their queries, even on repeated reminders, and lastly,  
3. The authenticity and accomplishment of documents produced by the complainant not   being established.

However, they made it clear that the case   might be reviewed on submission of required   documents.

Regarding the grounds No. (ii)  & (iii) for rejection of the claims, we find OPs failed to give anything in details about their specific queries beyond what they demanded from the complainant by email dated 15.06.2021 and 28.06.2021. The contents of both the said two emails are the same requiring the complainant to submit  hospital bills with break up and the documents relating to  ailments  of  hypertension, hypothyroidism etc. of the  complainant. The complainant claimed to have complied   with the request by sending the documents as sought for.

OPs also failed to specify and point out   any particular document or documents – the authenticity of which seemed questionable to them or in other words, they   were not satisfied with the genuineness of the documents and also the reasons therefor.

However, we assume, most probably, the certificate which is disputed by the OPs might have been regarding the document relating to ailment of hypertension etc. of the complainant which was subsequently sought.

We find the OPs produced a copy of the medical certificate issued by Dr. Asis Mitra (Annexure-E) and the said certificate was dated 05.07.2021 where the complainant was said to be suffering from hypertension, hypothyroidismsm etc. from 03.02.2021 though overwriting is found there on the date in the medical certificate.

But strangely enough, no question in this regard was put in the questionnaire issued to the complainant on their behalf.  If the OPs really had any doubts about any such documents, they could have got it cleared from the complainant through questionnaire. But they didn’t do so for reasons best known to them.

This apart, it’s very common, a large number of people in the modern days with fast paced life, more or less suffer from the ailments relating to hypertension etc. which may not be the actual cause of other unrelated ailments.

On the other hand, we find the complainant submitted all the medical papers relating to his treatment in the said Medica Super-specialty Hospital, and also the hospital bill showing break up under different heads of expenditure. Complainant claimed re-imbursement of the medical expenditure in connection with the treatment of his Covid-19 Pneumonia for which he got admitted to the hospital.  In this context, how the aforesaid documents which were submitted by the complainant failed to qualify to be in the category of “mandatory claim documents”?  Frankly speaking, this is absolutely beyond our intellectual horizon. No explanation is forthcoming from the OPs in this regard. Therefore, rejection of the claim of the complainant for re-imbursement of his medical expenditure altogether is something like whimsical and bereft of any logical grounds and thereby giving credence to the claim/allegation of the complainant about deficiency in service on the part of the opposite parties.

Complainant is also found to have made the claim in connection with his treatment which took place during the period when the policy remained in force.  Such claim for re-imbursement was also submitted within 30 days from the date of his discharge from the hospital.

Be it noted here, in the brief notes of argument, OPs cited several decisions namely General Assurance Society Ltd.  V  Chandmull Jain (1966) 3 SCR 500 relating to interpretation of document to a contract of insurance, Oriental Insurance Co. Ltd.  V.  Samayanallur primary Agricultural Co-op. Bank AIR 2000 SC 10 and Polymat India P. Ltd. and Anr. V. National Insurance Co. Ltd. and ors, 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.

        We have gone through the said decisions but we hold, here in this case these decisions would be of no assistance to the OPs.

Complainant claimed to have paid Rs.2,93,606/- to the hospital for his treatment. This amount is the aggregate of expenditure under different heads which is clear from the  break up  bills. 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, we find out of the service names in the break up bills, food and beverages item amounting Rs.229/- is not allowable. Likewise, under IP Surgical Disposables, several items are not allowed, namely, ounce thermometer, ECG Electrode etc. So, in our opinion, out of the claim of Rs.2,93,606/-  a sum of Rs.2,85,000/- can be allowed. With this, a further sum of Rs.5812/- for expenses towards pre-post hospitalization period, thereby making an amount of Rs.2,90,812/-in total  which can be allowed in this case. Complainant is also entitled to interest on this amount @ 7% p.a. from the date of 05.07.2021 which is the date of communication of repudiation of the claim  through email by the OPs.

All the points are thus, disposed of.

Hence,             it is

ORDERED

That the instant complaint be and the same is allowed on contest against the OPs.

Complainant is entitled to Rs.2,90,812/- (two lakh ninety  thousand eight hundred twelve only) towards re-imbursement of his medical expenses from the OPs along with interest @ 7% p.a. from 15^th July 2021 until realization.

Complainant is also entitled to Rs.5000/- (five thousand only) towards cost of litigation.

All the OPs who are jointly and severally liable, are directed to pay the said amount within 45 days from the date of this order failing which the complainant shall be at liberty to realize the same in accordance with law.

Dictated and corrected by me.