DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, ERNAKULAM
Dated this the 29th day of February 2024.
Filed on:20.05.2023
PRESENT
Shri.D.B.Binu President
Shri.V.Ramachandran Member Smt.Sreevidhia.T.N Member
C.C NO.320/2023
COMPLAINANT
Renjith.R , SreerangamHouse Erumathala Po, Keezhmad, Aluva,
PIN-683 112
OPPOSITE PARTY
Universal Sompo General Insurance Company Limited., TR/54/3106-C, 2nd Floor, Grace Corner, K.K.Road, Kadavanthra Junction, Kadavanthra, Kochi, Kerala 682020,
F I N A L O R D E R
D.B. Binu, President.
1. A brief statement of facts of this complaint is as stated below:
This complaint was filed under Section 35 of the Consumer Protection Act, 2019. The complainant's spouse, Sreevidhya B, became unwell and was hospitalized at V.G. Saraf Memorial Hospital in Kochi on August 4, 2022, due to severe abdominal pain. Upon a comprehensive examination, it was discovered she was suffering from gallstones. The attending physician alerted the emphasized the necessity of immediate surgery to prevent life-threatening complications. The surgical procedure was completed, and the patient was discharged on August 9, 2022. The total medical expenses incurred amounted to INR 1,33,509. A detailed invoice for the treatment and medication, along with the application, was dispatched to the opposite party via speed post on August 29, 2022, with relevant details provided and the Policy Customer Card. Despite reaching out to the opposite party both telephonically and in person, the petitioner has yet to receive any update on the claim status.
The complainant seeks the following reliefs:
- Reimbursement of treatment expenses: INR 1,33,509
- Compensation: INR 50,000
- Anticipated future medical expenses: INR 35,000 Total claim: INR 2,18,509.
2) Notice
The notice issued to the opposite party was dispatched by the Commission. Despite acknowledging receipt of this notice, the opposite party failed to submit their version. Consequently, they have been set as ex-parte in this proceeding.
3) . Evidence
The complainant had filed an ex-parte proof affidavit and 3 documents that were marked as Exhibits-A-1 to A-3.
Exhibit A-1: Doctor's Certificate - Documentation certifying the medical diagnosis and the necessity for immediate surgical intervention for Sreevidhya B, following her admission to V.G. Saraf Memorial Hospital, Kochi, on August 4, 2022, due to severe abdominal pain caused by gallstones.
Exhibit A-2: Detailed Treatment Bill - Comprehensive billing statement covering the total medical expenses incurred during the hospitalization and treatment of Sreevidhya B, amounting to INR 1,33,509. This includes all procedural and medication costs associated with her surgery and subsequent recovery, discharged on August 9, 2022.
Exhibit A-3: Policy Customer Card - Proof of the health insurance policy under which the claim is being filed, demonstrating the petitioner's entitlement to coverage for the medical expenses incurred due to Sreevidhya B's illness and treatment.
4) The main points to be analysed in this case are as follows:
i) Whether the complaint is maintainable or not?
ii) Whether there is any deficiency in service or unfair trade practice from the side of the opposite party to the complainant?
iii) If so, whether the complainant is entitled to get any relief from the side of the opposite party?
iv) Costs of the proceedings if any?
5) The issues mentioned above are considered together and are answered as follows:
In the present case in hand, as per Section 2(7) of the Consumer Protection Act, 2019, a consumer is a person who buys any goods or hires or avails of any services for a consideration that has been paid or promised or partly paid and partly promised, or under any system of deferred payment. A copy of the Policy Customer Card - Proof of the health insurance policy under which the claim is being filed, demonstrating the petitioner's entitlement to coverage for the medical expenses incurred due to Sreevidhya B's illness and treatment.
The receipt evidencing payment to the opposite parties (Exhibits A-3). Hence, the complainant is a consumer as defined under the Consumer Protection Act, 2019.
The evidence presented included an ex-parte proof affidavit filed by the complainant, and it was unchallenged by the opposite party. Therefore, the complainant's claims were considered credible and supported by the evidence. Therefore, the complainant requests the commission to grant the relief sought, including compensation for mental agony and unfair trade practices.
The opposite parties’ conscious failure to file their written version in spite of having received the Commission’s notice to that effect amounts to an admission of the allegations levelled against them. Here, the case of the complainant stands unchallenged by the opposite parties. We have no reason to disbelieve the words of the complainant as against the opposite party. The Hon’ble National Commission held a similar stance in its order dated 2017 (4) CPR page 590 (NC).
The complainant sought relief for the deficiency in service and unfair trade practice on the part of the opposite party, specifically in their failure to reimburse medical expenses incurred for the treatment of Sreevidhya B.
Findings and Legal Reasoning:
- Maintainability of Complaint: The complaint is maintainable under the Consumer Protection Act, 2019, as the complainant qualifies as a consumer. The evidence, including the Policy Customer Card (Exhibit A-3), establishes the complainant's entitlement to claim coverage for medical expenses under the insurance policy.
- Deficiency in Service and Negligence: The opposite party's failure to respond to the complainant's claims, despite acknowledgment of the notice issued by the commission, constitutes a deficiency in service and negligence. The evidence presented by the complainant, including the Doctor's Certificate (Exhibit A-1) and Detailed Treatment Bill (Exhibit A-2), substantiates the claim for medical expenses incurred due to necessary medical treatment.
- Relevant Case Laws: Drawing from precedent, the Hon’ble National Commission in the order dated 2017 (4) CPR page 590 (NC) highlighted that an opposite party's failure to file a written version or respond to a commission's notice is tantamount to an admission of the allegations made against them. This principle applies in the present case, supporting the complainant's position.
- Liability of the Opposite Party: Based on the analysis and the principles of justice and fairness embodied in the Consumer Protection Act, 2019, the opposite party is found liable for the deficiency in service. Consequently, they are obligated to fulfil the complainant's claim for reimbursement of medical expenses, compensation for mental agony, and costs associated with unfair trade practices.
Considering the evidence, supported by the unchallenged affidavit and documentation, credibly demonstrates a clear case of deficiency in service and unfair trade practices on the part of the opposite party. The failure to engage with the claims process and provide timely updates further exacerbates this finding.
We determine that issue numbers (I) to (IV) are resolved in the complainant's favour due to the significant service deficiency and unfair trade practices on the part of the opposite party. Consequently, the complainant has endured considerable inconvenience, mental distress, hardships, and financial losses as a result of the negligence of the opposite party.
In view of the above facts and circumstances of the case, we are of the opinion that the opposite party is liable to compensate the complainant.
Hence the prayer is partly allowed as follows:
I. The Opposite Party shall reimburse ₹1,33,509/- (One Lakh Thirty-Three Thousand Five Hundred and Nine Rupees) towards the treatment expenses of the complainant's spouse.
II. The Opposite Party shall pay ₹40,000/- (Forty Thousand Rupees) towards compensation for the deficiency in service and unfair trade practice committed by the opposite party, and for the mental agony and physical hardships sustained by the complainant.
III. The Opposite Parties shall also pay the complainant ₹10,000/- (Ten Thousand Rupees) towards the cost of the proceedings.
The Opposite Party is liable for the above-mentioned directions which shall be complied with by the Opposite Parties within 30 days from the date of the receipt of a copy of this order. Failing which, the amount ordered vide (I) and (II) above shall attract interest @ 9% per annum from the date of filing of the case (20.05.2023) till the date of realization.
Pronounced in the Open Commission on this 29th day of February 2024.
Sd/-
D.B.Binu, President
Sd/-
V.Ramachandran, Member
Sd/-
Sreevidhia.T.N, Member
Forwarded by order
Assistant Registrar
Forwarded/by Order
ssistant Registrar
appendix
Exhibit A-1: Doctor's Certificate - Documentation certifying the medical diagnosis and the necessity for immediate surgical intervention for Sreevidhya B, following her admission to V.G. Saraf Memorial Hospital, Kochi, on August 4, 2022, due to severe abdominal pain caused by gallstones.
Exhibit A-2: Detailed Treatment Bill - Comprehensive billing statement covering the total medical expenses incurred during the hospitalization and treatment of Sreevidhya B, amounting to INR 1,33,509. This includes all procedural and medication costs associated with her surgery and subsequent recovery, discharged on August 9, 2022.
Exhibit A-3: Policy Customer Card - Proof of the health insurance policy under which the claim is being filed, demonstrating the petitioner's entitlement to coverage for the medical expenses incurred due to Sreevidhya B's illness and treatment.
