Complaint filed on: 16-01-2021

                                                      Disposed on: 02-03-2022

BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, TUMAKURU

CC.No.10/2021

DATED THIS THE 2^nd DAY OF MARCH, 2022

PRESENT

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

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

Complainant: -

Sri.Ramesh.N.S,

S/o N.K.Sathyarayana Shetty

Aged about 49 years,

Residing at No.39,

Near Sukadha, Amrutha water Purifier, Manjunatha Nagara,

TUDA layout,

Tumakuru city     

(By Sri.G.K.Srinivasa, Advocate)

V/s

Opposite parties:-    

1. The Branch Manager,

IFFCO TOKIO General Insurance Co. Ltd, Brindavana Building, Ground Floor, P-6 (d), 1^st Main, 1^st Stage, Peenya Industrial Area, Bengaluru

2. The Managing Director,

Sri Siddaganga Hospital

Pvt. Ltd

Dr.Sree Sree Shivakumara Swamiji Road, (BH Road) Tumakuru-572 102

(OP No.1 - By Smt.Jyothi.B, Advocate)

(OP No.2 – By Sri.M.R.Nagabhushana, Advocate)  

ORDER

SRI.KUMARA.N, PRESIDENT (I/c)

        This complaint was filed under Section 35 of the Consumer Protection Act, 2019 to direct the Opposite parties (hereinafter called as OPs) to pay the medical bill amount of Rs.1,38,992-00 with interest from 17-11-2020 till its realization and pay a sum of Rs.5,00,000-00 towards mental pain, agony etc. along with 12% per annum, in the interest of justice and equity.

          2. It is the case of complainant that, he has purchased the health insurance policy called “Corona Kavacha” from the 1^st OP by paying premium of Rs.8,466.92, accordingly the 1^st OP issued the said policy in the name of complainant bearing no.H0385029 and risk coverage between 3-9-2020 to 31-5-2021 and sum assured was Rs.5,00,000-00. The complainant further submitted that due to Covid positive, he admitted in the 2^nd OP hospital for treatment on 9-9-2020 as inpatient and discharged on 13-9-2020 accordingly the 2^nd OP hospital charged Rs.1,38,932-00 towards treatment charges. The complainant further submitted that at the time of admission to the 2^nd OP hospital the complainant requested the 2^nd OP hospital staff and informed regarding having Corona Kavacha health insurance policy and to make necessary arrangement to bill settlement in the said Corona Kavacha policy, but the 2^nd OP not informed to the 1^st OP thereby the 2^nd OP hospital shown deficiency in service. The complainant submitted claim from along with necessary documents to the 1^st OP and 1^st OP allowed only a sum of Rs.27,000-00 and refused to pay rest of the bill amount. The complainant further submitted that at the time of taking the said policy the 1^st OP assured that this policy is comprehensive insurance policy and the 1^st OP will reimburse all expenses incurred for the said disease, but the 1^st OP not allowed medical bills. Further the complainant issued legal notice to OPs on 17-11-2020 to settle the medical bills of Rs.1,38,932-00 as the OPs not responded. Hence, this complaint.

          3. The 1^st OP has appeared through its learned counsel and filed version, and admitting the facts that said Corona Kavacha policy issued by the 1^st OP to the complainant for a sum of Rs.5,00,000-00,  by collecting premium amount of Rs.8,466.92 and risk coverage between 3-9-2020 to 31-5-2021. Further submitted that they reimbursed the amount of Rs.27,000-00 against the claim of Rs.1,38,992-00 to the complainant, and rest of the amount not allowed due to GIC guidelines. The complainant policy covered under one of our indemnity policies-CKI and as per the GIC guidelines for COVID treatment and this OP has honored the claim partly as per GIC per day charges for COVID treatment hence, this OP is not liable to pay any further compensation to the complainant and this complaint is liable to be dismissed with cost. 1^st OP denies that claimant claim has completely rejected without paying amount and averments made in the complaint denied and false and put to strict proof of the same. There is no deficiency of service on the part of the 1^st OP hence, the 1^st OP prayed to dismiss the complaint.

          4. The 2^nd OP has appeared through its learned counsel and filed objection admitting that the complainant admitted in the 2^nd OP hospital due to Covid-2019 as inpatient from 9-9-2020 to 13-9-2020 and treatment given and charged Rs.1,32,992.00. Further the 2^nd OP submitted that the complainant has paid Rs.40,000-00 on 9-9-2020 i.e. at the time of admission and rest of the amount paid at the time of discharge. As the complainant alleged that the 2^nd OP not informed to the 1^st OP regarding complainant admission, treatment and billed amount claim under Corona Kavacha policy, the 2^nd OP denied as complainant opted for treatment by cash.  Further submitted that if the 1^st OP sought any clarification regarding the complainant policy claim we are ready to submits the facts so that the complainant get reimbursement from the 1^st OP. Hence, there is no deficiency in service on the part of the 2^nd OP and prayed to dismiss the complaint against the 2^nd OP.

5. The complainant filed affidavit evidence and produced Exs.P1 to P17 documents. On behalf of the 1^st OP one Gourish Bhat, Legal Executive has filed affidavit evidence and produced Ex.R1 to R3 documents and on behalf of 2^nd OP one Nagabhushana Rao.K.V, H.R. Manager and GPA holder of Managing Director of Sree Siddaganga Hospital as filed affidavit and produced legal notice dated 17-11-2020 issued by the complainant to OPs and reply notice of OPs dated 1-12-2020 along with postal acknowledgments.  

6. We have heard the oral arguments of complainant and OP no.1 and 2 and the points that would arise for determination are as here under:

1)      Whether the complainant proves that the there is deficiency of service part of OPs?

2)      Is complainant entitled to the reliefs sought for?  

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

Point No.1: In the affirmative   

Point No.2: In the partly affirmative for the

                   below;

REASONS

          8. Point No.1 and 2: The learned counsel for the complainant argued that at the time of purchase of said policy the OP stated as said Corona Kavach Policy Specialised indemnity product for the treatment of COVID-19 which was ideal armour that will shield you against costly medical bills while ensuring you get access to the best treatment that you do deserve. The complainant obtained Corona Kavacha policy from the 1^st OP, based on assurance of full reimbursement of treatment expenses of the said disease. The 1^st OP has not given any a specific terms and conditions of the policy and informed that this policy covered the reimbursement of Corona disease treatment expenses in all hospitals.

          9. The complainant filed documents which were marked as Exs.P1 to P9 which were medical bills, discharge summary and diagnosis report of complainant. Ex.P10 to Ex.P13,copies of Corona Kavacha policy, claim form repudiation of OP 1, legal notice, postal acknowledgment and reply of OPs to the complainant, which proves that Complainant obtained “Corona Kavacha” health insurance policy from the 1^st OP by paying premium of Rs.8,466.92,and risk coverage between 3-9-2020 to 31-5-2021, sum assured was Rs.5,00,000-00 and complainant admitted to the OP 2 hospital due to said disease and availed treatment as inpatient  between 9-9-2020 to 13-9-2020  accordingly complainant eligible for claim under the said policy.  

10. On perusal of the Ex.P10, the OP 1 allowed Rs.27,000-00 and not allowed room nursing charges of Rs.60,000-00, investigation charges of Rs.26,320-00 by giving reasons as “Broadly based on the schedule of rates suggested for covid-19 treatment by GIC council by considering Rs.6000/day for Type-A hospital in rest of country other than Metros and state capitals for isolation ward with Oxygen support”.

11. “Corona Kavacha” health insurance policy was specialised indemnity product for the treatment of COVID-19. Indemnity means making compensation payments to one party by the other for the loss occurred. Indemnity is based on a mutual contract between two parties (one insured and the other insurer) where one promises the other to compensate for the loss against payment of premiums.

12. From the above discussion we observed that, the 2^nd OP hospital when complainant at the time of admission to the 2^nd OP hospital due to said disease, informed the fact of having Corona Kavach health insurance policy to the 2^nd OP hospital but such crucial time the 2^nd OP hospital compelled the complainant to opt treatment under cash without considering the said health insurance policy, which accounts to negligence on the part of 2^nd OP hospital.

13. The terms and conditions of the insurance company not supplied to the insured. It was the duty of the insurance company to bring all the terms and conditions of the insurance policy to the specific note of the insured, in the absence of which same cannot be enforced upon insured. Hence, the OP no.1 is liable to pay repudiated the claim amount of Rs.86,320-00. Accordingly, we proceed to pass the following;

ORDER

The complaint is partly allowed with cost.

The OP No.1 liable to pay Rs.86,320-00 along with compensation of Rs.5,000-00 and litigation cost of Rs.6,000-00 to the complainant within 30 days from the date of this order failing which, it shall carries interest @ 8% per annum from the date of complaint till its payment.

Further it is ordered that the 2^nd OP hospital is liable to pay compensation of Rs.6,000-00 to the complainant within 30 days from the date of this order failing which, the 2^nd OP hospital shall pay interest @ 8% per annum from the date complaint till the date of payment.

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

          (Dictated to the Stenographer, got it transcribed, corrected and then pronounced in the Open Commission on this the 2^nd day of March, 2022).

LADY MEMBER                          PRESIDENT (I/c)