IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 31st day of July, 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M.Anto, Member
CC No. 300/2021 (Filed on 17-11-2021)
Complainants : Jacob Sebastian,
S/o. Sebastian,
Kappil veed,
Vallichira P.O.
Vallichira village,
Meenachil Taluk,
Kottayam – 686574
(Adv. Ratheesh K. Mohan)
Vs
Opposite party : United India Insurance Company Ltd.
Rep. by Manager,
United India Insurance Company,
Pala Branch, Branch Office,
Puthettu Arcade,
Near Kottaramattom bus stand,
Pala – 686 575
(Adv. P.G. Girija)
O R D E R
Smt.Bindhu.R, Member
The complainant took a health insurance policy from the opposite party on 10th December 2005 paying the premium continuously without any default in the policy number 1005072 820 P 110174574. The policy was effective from 10.12.2020 to 9.12 21. Complainant, his wife and children are covered by the policy. On 8.12.2020 the complainant paid rupees Rs.13,500/- for renewing the policy and the said policy was valid from 10.12.2020 to 9/12/2021. In January 2021 the complainant was admitted in Caritas hospital for headache and neck pain. Several tests for finding the reason of dizziness like sleep study was conducted and for headache MRI cervical spine and MRI scan brain were done. There after according to the above examinations it was found that the complainant had cervical myloradiculopathy, Occipital neuralgia obstructive sleep upnia, hypo thyroidism dislipidemia. Complaint was discharged on 23/1/21 after the treatment and buying the prescribed medicines. During this period the complainant had to pay rupees 28, 843/- on 23-1-21. The complainant is eligible for rupees 1,00,000/- as per the policy conditions. On 25 -02- 21 the complainant filed a claim with the opposite party for reimbursement along with the bills of 13,343/-and Rupees 15,500 to a total of Rs.28,843/-. All the documents were also submitted before the opposite party. All the documents given were originals. There after several times enquiries were made from the opposite party office but no amount was given by the opposite party towards the settlement of the claim till date. In 2020 the wife of the complainant had to undergo Ayurveda treatment of back pain and knee treatment for which rupees 70,000/- was incurred which was also claimed but not awarded by the opposite party till date. For that also the opposite party has received all the documents in originals from the complainant. The act of the opposite party after receiving premium regularly from 2005 is a clear deficiency of service on the part of the opposite party. The complainant is a consumer of the opposite party. The opposite party is bound to pay the claimed amount and hence the complaint is filed for obtaining a direction to the opposite party to pay Rs.31,723/- including 9%interst for the claim amount of Rs.28,843/- along with cost and compensation.
Upon notice the opposite party appeared and field version through it’s Divisional Manager. The opposite party admitting the policy contended that the complainant was admitted in the hospital only for investigation / lab test and not
for any treatment. The bills for an amount of Rs.15,500/- were for certain test only
and the bill for Rs.13,345/- was also for the investigations done and not on account
of any treatment. Even the hospitalization was also not required and it was done
only for the purpose of availing the Insurance claim. Hence as per the policy the
complainant is not entitled to get Rs.28,843/- as claimed from the opposite party.
The complainant was required to submit the certain documents after the submission of claim form on 25.2.21. On 21.3.21 the opposite party sent a letter to the complainant requesting production of the documents such as complete set of indoor case records with treatment chart, clarification from treating doctor regarding the need for hospitalization, clarification for delay in submission of claim documents. The complainant did not respond to the letter or submit the documents. Hence the opposite party was unable to process the claim of the complainant instead of submitting the required documents which were necessary for processing the claim of the complainant straight away filed this complaint. There is no deficiency in service on the part of the opposite party as alleged. Hence the complaint is not filed with any bonafides and is only liable to be dismissed.
The complainant has filed evidence affidavit along with documentary evidence. The documents filed by the complainant are marked as Exhibits A1 to A6.The opposite party also filed proof affidavit and marked Exhibits B1 and B2.
On the basis of the pleadings and evidence, we consider the issues to be answered are
- Whether the inaction of the opposite party on the policy claim of the complainant is a deficiency in service?
- If so what are the reliefs the complainant is entitled for?
Issue Nos.1 and 2
The case of the complainant is that he had taken a policy of no.1005072820P110174574 for a sum assured of Rs.1,00,000/- each from the opposite party covering himself and his family from 2005. In 2021 in the policy period itself the complainant was hospitalized for some neuropathic reasons for 3 days. When he submitted the claim for the refund of the bill amount, the opposite party neither approved nor rejected the claim. On the other hand the opposite party contented that the complainant had no necessity to have hospitalized but did so only for getting insurance amount.
Exhibit A2 and A3 are the test reports of the complainant. Exhibit A4 is the discharge summary issued from Caritas Hospital which shows that the complainant was admitted there from 21.01.21 to 23.01.21.The diagnosis is recorded as cervical myeloradiculopathy, occipital neuralgia, obstructive sleep apnea,hypothyroidism and dyslipidemia. A4 is issued and signed by Dr. Joseph Sebastian.
The opposite party contended that there was no need for hospitalization and
the complainant was hospitalized only for the purpose of getting the insurance amount. But it is the settled position that it is not the insurer who decide whether hospitalization is necessary or not. It is the treating doctor who should decide whether the patient is to be admitted or not. Moreover, some procedures need continuous observation, tests and support for which hospitalization might be necessary. Here as per the documents submitted by the complainant it is evident that he had undergone some neuropathic examinations which seems to be very necessary for the correct diagnosis. An accurate diagnosis only can lead to a correct treatment. So the process of diagnosis cannot be taken separately. Moreover, it is the treating doctor who should decide whether a treatment is given or not after the complete diagnosis. The insurer has no role in it. The insurer cannot evaluate the quality of treatment or necessity of treatment.
Moreover, the duty of an insurance company is to award or repudiate the claim received by them within 30 days after receiving all the documents. The opposite party received the claim on 25.2.21 but on 17-03-2021 they sent the letter demanding some more documents such as the requirement for the clarification from treating doctor for the need for hospitalization is arbitrary. The treating doctor has already issued the discharge summary and that was submitted by the complainant. In many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control.
The complainant was given medicines during hospitalization which is evident from the Exhibit A5 bills. Moreover, on discharge also medicines were prescribed. So the insurer cannot say that the hospitalization was not necessary. The complainant is advised medication on discharge also. So the contention of the opposite party is not sustainable. After receiving premium for a long period, the opposite party is liable to award the claim of the complainant. In answer to the issues framed, we find that both the issues are resolved in favour of the complainant.
Hence we allow the complaint and pass the following order:
(1) The opposite party is directed to pay Rs.28,843/- (Rupees Twenty eight thousand eight hundred and forty three only) to the complainant along with an interest @9% p.a from the date of filing 17.12.21 till realization.
(2) The opposite party is further directed to pay Rs.5000/- (Rupees Five thousand only) as compensation and Rs.2000 (Rupees Two thousand only) towards litigation cost to the complainant.
The order shall be complied within 30 days failing which the compensation amount shall carry 9 % interest from the date of receipt of the copy of this order.
Pronounced in the Open Commission on this the 31st day of July, 2023
Smt. Bindhu.R, Member Sd/-
Sri. Manulal.V.S, President Sd/-
Sri. K.M.Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of policy No. 1005072 820 P 110174574
A2 series – Copy of scan reports issued by Jeevan MRI Centre (4 nos.)
A3 – Copy of lab report issued by Caritas hospital
A4 – Copy of discharge summary dtd.23-01-2021 issued by Caritas hospital
A5 series- Copy of discharge bill dtd.23-01-2021 issued by Caritas Hospital
(6 nos.)
A6- copy of claim form
Exhibits marked from the side of opposite party
B1 – Copy of policy No.1005072 820 P 110174574
B2 – Letter dtd.21-03-21 by opposite party to complainant
By Order
Assistant Registrar
