Complaints filed on: 29-12-2020

                                                      Disposed on: 21-01-2022

BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, TUMAKURU

CC.No.90/2020

DATED THIS THE 21^st DAY OF JANUARY, 2022

PRESENT

SRI.KUMARA.N, B.Sc., L.L.B, PRESIDENT (I/c)

SMT.NIVEDITA RAVISH, B.A., L.L.B, LADY MEMBER

Complainant: -

Manu.T.U

S/o Umadeva.T.A

Aged about 38 years,

R/at 2^nd Floor, Dhanalakshmi Bank Building, Valmiki Nagara, Tumkur-572103  

Working at: Professor, PGDMS and Research Centre, SIT, Tumakuru-572 103    

(By Sri.R.Raghu, Advocate)

V/s

Opposite party:-       

Universal Sompo General Insurance Co. Ltd,

Assotech one, 5^th Floor,

C-20/1A, C-Block, Sector-62, Noida, Uttar Pradesh-201309

(Exparte)

ORDER

SMT.NIVEDITA RAVISH, LADY MEMBER

This complaint has filed under Section 35 of Consumer Protection Act, 2019 to direct the Opposite Party (hereinafter called as OP) to pay Rs.43,960-00 with simple interest and Rs.10,000-00 as compensation to the complainant in the interest of justice.  

2. It is the case of complainant that, the complainant has insured Covid-19 insurance policy in the OP company. As per the insurance policy No.2839/61164336/00/ 036, it was a group health insurance and master holder is the Karnataka Bank Ltd. The certificate bearing No.61164336/24510 and the risk commencement date 28-10-2020 and the policy insured amount is Rs.3,00,000-00. On 4-9-2020 the complainant has admitted to Siddaganga Hospital and Research Institution for Covid-19 disease and discharged on 8-9-2020. The total hospital expenditure bill amount of Rs.1,40,179-00 and the OP insurance company has paid only a sum of Rs.72,579-00, but the OP insurance company has refused to pay the medicine, consumable charges and investigation charges Rs.21,870-00 and Rs.22,090-00 total Rs.43,960-00. According to the policy, it is a duty and responsibility of the OP insurance company to pay a sum of Rs.43,960-00 towards medicine, consumable and investigation charges. In this regard, the complainant has approached the OP many times and requested them to pay the above said amount but the OP has refused the complainant requests and requisitions hence, this complaint.    

3. After registering the complaint, notice was issued to the OP. Despite service notice, the OP has not appeared and placed exparte.

4. The complainant has filed his affidavit and produced Group health insurance certificate of insurance and claim settlement letter. The complainant has also filed written arguments.

5. We have heard the oral arguments of learned counsel for complainant and points that would arise for determination are as under.

1. Whether the complainant proves the deficiency on the part of OP in not releasing the part of claimed insurance amount?
2. Is complainant entitled to the reliefs sought for?

6. Our findings on the aforesaid points are as follows:

Point No.1: In the negative    

Point No.2: As per final order for the below

REASONS

7. Point No.1 and 2: The learned counsel for the complainant has submitted that the OP has refused to pay part of claimed insurance amount. Further the complainant in his affidavit has reiterated the averments of complaint.

8. The complainant has produced group health insurance certificate dated 19-4-2020 issued by the OP which shows that that the policy was in force whereas risk commencement date was 30-6-2020 and risk end date was 28-10-2020.

9. The complainant in his complaint, affidavit and written arguments mentioned the risk commencement date was 28-10-2020 and he has admitted in the hospital on 4-9-2020 which shows that he has admitted before commencement of policy which is contrary. Further the complainant prays for part of claim amount which were medicine and consumable charges of Rs.2,870-00 and investigation charges Rs.22,090-00 totally Rs.43,960-00. For which, the complainant has not produced the conditions attached to the policy which were describes about the medicine, consumable charges and investigation charges.

10. Further the complainant produced claim settlement letter in which the OP has mentioned the reasons for not paid amount. The OP has given the reasons for not paid the amount as they have deducted the amount “as per Karnataka State Govt. norms Covid-19 package applicable to isolation ward Rs.10,000-00/day”. The complainant has not produced any documents, notification of Karnataka Government and hospital bills and not made the treated hospital as a necessary party to the proceedings. Further the complainant has submitted that the complainant has made many approaches and requests to the OP, but the complainant has not produced any documents to prove the same.  Hence, we come to conclusion that the complainant has failed to prove deficiency of service on the part of OP insurance company and accordingly, we proceed to pass the following:

ORDER

The complaint is dismissed without costs.

Furnish the copy of order to the complainant and opposite party at free of cost.

          (Dictated to the Stenographer, got it transcribed, corrected and then pronounced in the Open Commission on this the 21^st day of January, 2022).

LADY MEMBER                                         PRESIDENT (I/c)