FINAL ORDER/JUDGMENT
SMT. SUKLA SENGUPTA, PRESIDENT
This is an application U /s 35 of CP Act, 2019 filed by the complainant.
The fact of the case in brief is that the complainant obtained an Health Insurance Policy being No. 0000000004658661 from the OP on 08.07.2017 for sum assured of Rs.1,00,000/- which is renewal in nature in every year at a premium of Rs.2,600/- annually. Accordingly since 2017 the OP has renewed the policy of the complainant till 2019 valid upto midnight of 07.07.2020 on receipt of the required premium of the said renewed policy being No. 0000000004658661-03.
It is further stated by the complainant that in the month of April 2020 the complainant felt chest pain and heart problem then he consulted with specialist doctor in the month of April 2020 onwards over phone as the public transport were shut down due to pandemic situation. On 01.05.2020 the complainant was severely suffering from fever and breathing problem and was admitted at Calcutta Heart Clinic and Hospital i.e. the OP-5 of this case. He went to the hospital by ambulance. After his admission in hospital named above few necessary tests were done in the hospital and was allotted to a fever bed in a room of multi bed. He was diagnosed with negative with Covid-19 then he was shifted to a non fever bed in the said hospital on 03.05.2020.
The complainant further stated that at that time no normal non-fever bed was available in the hospital and for that reason he was shifted to a cabin bed for his further treatment.
The complainant compelled to take the cabin. Thereafter the complainant tried to get the cashless claim of his medical treatment through the hospital (OP-5) and the OP-5 tried to get contact with the Insurance Co. i.e. OP-1 to 4 for cashless treatment but in vain. Thereafter the complainant was discharged from the hospital on 04.05.2020 and paid the entire bill of the hospital amounting to Rs.42,252/- from his own pocket. The complainant was discharged from the hospital with instruction by the doctors for check up after a month from the date of discharge. After check up the complainant submitted all the relevant documents relating to his expenditure and treatment since admission for the settlement of the claim to the OP-1. He claimed the pre hospitalization expenses occurred from 26.04.2020 upto post hospitalization expenditure amounting to Rs.51,963/-. The claim was submitted on 23.06.2020 and the OP acknowledged the receipt in 07.07.2020. But on 10.07.2020 the complainant received the settlement claim amounting of Rs.10,000/- instead of Rs.51,963/-. On account of pharmacy and medicine of Rs.16,019/-, only Rs.2,351/- was sanctioned but the complainant is entitled to get the full pharmacy and medical amount of Rs.16,019/-. It is alleged by the complainant that the OPs have sanctioned a sum of Rs.10,801/- only out of Rs.51,963/-. On account of pharmacy and medicine the amount of Rs.16,019/- but out of which only Rs.2,351/- was sanctioned by the OPs without having any reason. Hence, the complainant requested the OPs to settle the claim of Rs.59,760/- as per his claim application but the OPs did not pay any heed to his words hence the petition of complaint is filed by the complainant with a prayer to give direction to the OPs to settle the claim of Rs.40,162/- to the complainant along with interest @18% p.a. till the date of actual payment with paid premium of Rs.7,800/-. The complainant further prayed for giving direction to the OPs to pay compensation of Rs.50,000/- for deficiency in services harassment, mental pain and agony along with litigation cost of Rs.30,000/-.
The OPs-1, 3 and 4 have contested the claim application by filing a written version denying all the material allegations leveled against them.
The OPs-2 and 5 did not contest the claim application by filing WV hence, the case do run ex parte against them vide order dated 23.03.2023.
It is stated by the contesting OPs in their WV is that the petition of complaint is not tenable in law as there is no deficiency in service and unfair trade practice on the part of the OPs. The OPs further stated that they have validly settled the claim as per the coverage offer and within the precincts of the terms and condition of the policy in question. There was no outstanding consumer dispute in between the complainant and the contesting OPs so the petition of complaint is not tenable in the eye of law and is liable to be dismissed.
It is alleged by the contesting OPs that the petition of complaint is frivolous, vague vexatious in nature. Admittedly the OPs have issued Group Health Insurance Policy being No. 0000000004658661-03 covering Mr. Uttam Kumar Samanta the complainant for the period of 23.07.2019 to 22.07.2020 for sum assured of Rs.1,00,000/-. The Policy in question was subject to certain terms, condition and exclusions mentioned in the policy (Annexure-1).
The contesting OPs further stated that the claim of the complainant is settled for Rs.10,801/- against the amount claimed for Rs.51,731/- towards medical expenses incurred for treatment of acute upper respiratory infection. The detailed breakdown of payment and deduction given by OP-2 dated 10.07.2020 (Annexure-2). It is denied by the contesting OPs that the deductions were made for no reason rather it was deducted as per terms and condition of the policy in question wherein payable and non-payable items are categorically mentioned and enlisted. As per OPs case the complainant has no cause of action to file the case and it is liable to be dismissed.
In view of facts and circumstances as above stated above, let it be decided
1. Whether the case is maintainable or not.
2. Has the consumer any cause of action to file the case.
3. Is the complainant a consumer.
4. Is the complainant entitled to get the relief as prayed for.
Decision with reasons
All the points of considerations are taken up together for convenience of discussion and to avoid unnecessary repetition.
On a close scrutiny of materials as well as evidence on record, it is found that the case is well maintainable in the eye of law and this commission has got ample jurisdiction to try this case.
Admittedly the complainant has purchased the questioned Group Health Insurance Policy No. 0000000004658661-03 covering the complainant Uttam Kumar Samanta for the period 23.07.2019 to 222.07.2020 for sum assured of Rs.1,00,000/- subject to certain terms, condition and exclusion mentioned in the policy.
It is the complainant’s case that in the month the April 2020 on 26.04.2020 the complainant faced the chest pain and heart problem and started to consult with specialist doctor over phone due to pandemic situation (Lock down) because of Covid-19. Thereafter on 01.05.2020 the complainant was severely affected with fever and breathing problem. He went to Calcutta Heart Clinic and Hospital, the OP-5 through ambulance service and was admitted therein. His treatment was started there. In the Hospital the complainant was allotted in a fever bed a negative room of multi bed until getting all the necessary tests results. He was diagnosed with Covid-19 and shifted to a non fever bed in the hospital. The complainant had no option but to avail the higher graded bed in the hospital. From the facts and circumstances of the case as well as evidecne as adduced by the parties it is revealed that on 04.05.2020 the complainant as discharged from the OP-5 hospital. The hospital charge amounting to Rs.42,252/- was paid in cash by the complainant on an expectation that the bill can be reimbursed after setting on by the OP-1 to OP-4 Insurance Co. and he returned home from the hospital by ambulance. The complainant further stated that the OP-5 hospital on their level best tried to contact to the OP-1 to OP-5 for cashless treatment but in vain. thereafter as per instruction of the attending doctor of the OP-5 hospital the complainant went to the hospital on 05.05.2020 for check up and he claimed the pre hospitalization expenses occurred from 26.04.2020 upto 28.05.2020 amounting to Rs. 51,963/- which was submitted by him to the OP-2 Claim Manager of the OP-1 SBI General Insurance Ltd. on 23.06.2020 which was acknowledged on 07.207.2020 by the OP-2. From the evidence on record it is found that the OP-2 only settled the claim to the tune of Rs.10,801/- out of Rs.51,963/- which compelled ignited the complainant to come before this Commission with his petition of complaint for getting the rest of his claim amounting to Rs.40,162/- along with interest @ 18% p.a.
Let us see whether the complainant is entitled to get the claim amounting of Rs.51,963/- in total minus Rs.10,801/- settled amount = (Rs.40,162/-). During the course of argument and also in the concerned BNA as faced by the OP-1, 3 and 4 because of the case do run ex parte against the OP-2 and OP-5 as they did not appear and contest the case.
It is the case of the contesting OPs that though admittedly the complainant purchased the questioned Group Health Insurance Policy No. 0000000004658661-03 from the OPs for the period of 23.07.2019 to 22.07.2020 for sum assured of Rs.1,00,000/- on terms, conditions and exclusion mentioned in the questioned policy. So the admitted portion of the claim in question of Rs.51,731/- has been sanctioned from the end of the OPs amounting to Rs.10,801/- as per terms and condition of the questioned policy. The complainant has argued he started to make contact with the doctors for his illness in the month of April 2020 and get medical consultation form 26.04.2020 over telephone which was continued upto 26.05.2020 but except the receipt of hospital charge amounting to Rs.42,252/- in total, though from the documents as submitted by the complainant it is revealed that the complainant went to the hospital and returned there from to home by ambulance of North Dumdum Municipality. But from the terms and conditions as well as exclusion clause of the questioned health policy it is found that the ambulance charged by which the complainant insured went to the hospital and returned these from and prior to the hospitalization as well as after hospitalization the pharmacy charge are also excluded in the terms and condition of the questioned policy. In this regard the complainant has cited a case law of the Hon’ble SC which has been referred as Pioneer Urban Land and Infrastructure Vs Govindan Raghavan on 02nd April, 2019. The Commission has carefully gone through the case mentioned and found that it has no application in the instant case because the facts and circumstances of the instant case is different from the referred case as mentioned above. But it is fact that the insured shall get the entire treatment expenses of the hospital which is amounting to Rs.42,252/- as per bill issued by the authority Calcutta Heart Clinic and Hospital where the complainant had admitted for his illness on 01.05.2020 and discharged on 04.05.2020. The complainant placed the bill to the OPs amounting to Rs.51,963/- on and from the date of 26.04.2020 upto 26.05.2020 that is post admission of the hospital and after discharge of the hospital. But this Commission on careful consideration of the terms and condition of the questioned policy by which by both the parties of this case being the insured and insurer are bound found it that the complainant only get the hospital expenses amounting to Rs.42,252/- instead of Rs.51,963/-. The OPs being the service provider though in their argument tried to evade from their responsibility to settle the claim in favour of the complainant and only paid a sum of Rs.10,801/- instead of Rs.42,252/-. From the evidence on record, it is categorically evident that on several occasions being the consumer as well as the insured the complainant requested the OPs to settle the claim but the OPs did not pay any heed to his requests, which caused harassment, mental pain and agony to the complainant in so many words such conduct of the OPs should be termed as deficiency in service on their part and they are bound to compensate the complainant for their misdeeds.
In view of the discussions made above, it is held by this Commission the complainant being a consumer could be able to prove his case in part against the OPs and is entitled to get the relief as prayed for.
All the points are considered and decided in favour of the complainant.
The case is properly stamped.
Hence,
Order
that the case be and the same is decreed on contest against the OPs-1, 3 and 4 and ex parte against the OPs-2 and 5 in part with cost of Rs. 5,000/-.
The complainant do get the decree in part.
The OPs are directed to pay a sum of Rs.42,252/-, the hospital expenses minus Rs.10,801/- paid amount by the OPs to the complainant = Rs.31,451/- to the complainant either jointly or severally within 45 days from this date of order.
The OPs are also directed to pay compensation of a sum of Rs.20,000/- along with litigation cost of Rs.5,000/- to the complainant either jointly or severally within 45 days from this date of order, i/d the complainant will be at liberty to execute the decree as per law.
Copy of the judgment be uploaded forthwith on the website of the Commission for perusal.
