Complaint filed on:18-04-2023.

                                                      Disposed on:10-01-2024

BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, TUMAKURU

DATED THIS THE 10^th DAY OF JANUARY, 2024

PRESENT

SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT

SRI.KUMARA.N, B.Sc. (Agri), LLB., MBA., MEMBER

SMT.NIVEDITA RAVISH, B.A., LLB. (Spl)., LADY MEMBER

CC.No.51/2023

Sri. Purushotham V S/o B.Venkataramana

A/a 54 years, R/a No.18 Kousthubha,

Beside Municipal water Tank, Vidyanagara,

Tumkur.

……………….Complainant/s

(By Sri.C.V.Ramachandra, Advocate)

                                                V/s

M/s Care Health Insurance,

Soundaray Sampige Office,

No.412/10, 1^st floor, 2^nd main,

8^th cross, Sampige Road,

Malleshwaram, Bangalore.

……………….Opposite Party/s

(By Sri.B.K.Chandrashekharaiah – Advocate)

: O R D E R :

BY SRI.KUMARA.N., MEMBER

This Complaint filed by the complainant to directed the OP to pay entire medical expenditure of Rs.55,939/- along with interest @ 18% from the date of admission to the hospital to till realization and further prays to direct the OP to pay Rs.2,00,000/- towards compensation for deficiency in service and unfair trade practice together with cost and such other reliefs.

2.       In this case the Opposite Party is M/s Care Health Insurance, Soundarya Sampige Office, No 412/10, 1^st Floor, 2^nd main.8^th Cross, sampige Road, Malleshwaram, Bangalore. (Hereinafter called the OP)

3.        It is the case of a complaint that the complainant has taken Family Health Care Insurance policy bearing No.30793328 on 21.03.2022 from the OP & since last five years, for Rs.5,00,000/- and paying premium of Rs.13,783/- every year, which is for him and his family members medical expenditure cover.  The complainant further submitted that on 18.04.2022, the complainant got admitted to ASTRA CMI Hospital at Bangalore to operate his Nape of Neck and right foot toe was operated and on the same day, the complainant intimated about the same to the OP and in turn the OP advised the complainant that the company was not tie up with the above said hospital for cashless services and suggested the complainant to produce the documents and medical expenditure bills after operation along with claim form.  It is further submitted that on 28.04.2022, the complainant approached the OP and submitted the claim form along with discharge summary and final medical bill for Rs.55,939/-, but till today, the OP did not settled the claim even after several approaches and phone calls.  The complainant is entitled for the medical expenditure bill as the policy was in force.  Hence, this complaint.  

4.        After the complaint registered, Commission notice was issued to the OP and in turn the OP appeared through its counsel and filed the version contending that the complaint is false and frivolous and complainant has not cause of action, hence complaint deserves to be dismissed.  The OP acted as per the terms and conditions of the policy document and declined to pay the claim of the complainant. It is further contended that the Insurance Company can only process the claim on receipt of all relevant documents and since the complainant herein has failed to fulfill the pre-requisite for rendering any claim admissible under the policy terms and conditions.  The claim of the insured has been rightly repudiated by the OP in strict adherence to the policy terms and conditions and as such there is no deficiency in service on the part of OP.  The OP further contended that a reimbursement claim was filed for the hospitalization of the complainant at Aster CMI Hospital on 18.04.2022 as he was diagnosed with scalp mass under evaluation, HPE awaited, protruding exostosis base of proximal phalanx (great toe) and upon receipt of claim, the query letter dated:05.07.2022 was raised and the complainant asked to provide investigation report supporting diagnosis and histopath/biopsy report and in also sent reminders to provide such documents and upon receipt of claim an investigation was also conducted to check the veracity of the claim and thereafter based on investigation they denied the claim vide letter dated:28.09.2022.  On these among other grounds, it is prayed to dismiss the complaint.

5. The complainant has filed his evidence by way affidavit evidence and marked the documents at Ex.C1 to C6. Sri.Prabhjyot Singh, Authorized Signatory of OP filed affidavit on behalf of OP.

6. .       We have heard the arguments of counsel for complainant.  In spite of sufficient opportunities, the OP failed to address their arguments.  Hence, arguments on OP taken as NIL.

7.        On perusal of pleadings, evidence and documents of both sides, the points that would arise for our consideration are:

8.       The points that would arise for our consideration are:-

1. Whether the complainant proves the deficiency in service on the part of OP?

2. Is complainant entitled to the reliefs sought for?

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

Point No.1: Partly Affirmative

Point No.2: As per below order

:R E A S O N S:

Point Nos.(1) & (2):-

10.     The complainant counsel argued that, the complainant obtained the family health insurance policy bearing No.30793328 on 21.03.2022 from the OP & since last five years, the sum assured was Rs.5,00,000/- and paying premium of Rs.13,783/- every year and the policy is in active, The complainant on 18.04.2022, admitted to ASTRA CMI Hospital at Bangalore & undergone treatment of  operate his Nape of Neck and right foot toe was operated and on the same day the complainant discharged. As there was no cashless services available with this hospital with the OP, as advised by the OP, the complainant paid treatment expenses of Rs .55,939.00 to the treated hospital, and submitted the claim along with necessary documents to the OP. The OP assured to settle the claim amount, even before this commission, but without settling prolonged the case intentionally. The policy is in active as on the date of the complainant taken treatment in the hospital and the complainant is entitled to get the claim amount of Rs 55939.00 from the OP, hence the complainant prayed to allow the case & award compensation. The complainant produced Ex C1, copy of the renewal of the insurance policy bearing No 30793328, wherein the policy active from 24-03-2022 to 23-03-2023 and complainant name reflected in insured list, Ex C2 copy of claim form, Ex C 3, copy of discharge summary, Ex C4 copy of summary bill for Rs 55939.89, Ex C5, copy of certificate dated 06-09-2022 from the treated hospital and Ex C6, copy of certificate dated 20-06-2022 from the treated hospital.

11.     Honorable Supreme court of India, the division bench of Justice Abhay S Oka and Justice Rajesh Bindal, in CIVIL APPEAL NOS. 2769-2770 OF 2023, in the case of Om Prakash Ahuja Vs Reliance General Insurance Co. Ltd, on July 04, 2023, held that, Medical Insurance - Once there is a valid insurance policy in favour of a person, the claim for reimbursement of the expenses incurred must be paid.

12.     In this case, in the above discussion, the complainant obtained family health insurance policy bearing No.30793328 on 21.03.2022 from the OP & sum assured was Rs.5,00,000/- and yearly premium was Rs.13,783/- and the policy is in active is not disputed. The complainant on 18.04.2022, admitted to ASTRA CMI Hospital at Bangalore & undergone treatment of operate his Nape of Neck and right foot toe was operated and on the same day the complainant discharged and the complainant submitted claim of Rs .55,939.00 to the OP is also admitted fact, the dispute is that, the OP after the receipt of claim from the complainant, while processing the claim, the OP raised query letter dated 05-07-2022 to provide HISTOPATH / Biopsy Report of the complainant to process the claim, but the complainant not produced the same inspite of reminder letter dated 12-07-2022 & 19-07-2022, but the OP not produced any evidences of query letter dated 05-07-2022 and the reminder letter dated 12-07-2022 & 19-07-2022. The complainant documents (Ex.C5 and Ex.C6) dated:06.09.2022 and 20.06.2022 reveal that the complainant not undergone HISTOPATH / Biopsy test in the treated hospital and the treated hospital given certificates stating that to avoid unnecessary expenses and which was not required, hence not conducted HISTOPATH / Biopsy test, and by typographical mistake our hospital discharge team in discharge summary(Ex.C3) mentioned that HISTOPATH / Biopsy conducted to the complainant.  Upon verification in summary bill (Ex.C4) HISTOPATH / Biopsy treatment charges/test charges not charged, which shows that the OP unnecessarily dodging the claim without settling the complainant claim which leads deficiency in service on the part of OP, hence the OP is liable to pay compensation of Rs.8,000-00 to the complainant. The OP unnecessarily compelled the complainant to approach this Commission, hence the OP is liable to pay litigation cost of Rs.8,000-00 to the complainant.  Accordingly, we pass the following:-    

-:O R D E R:-

The complaint is allowed in part with cost.

The OP is directed to pay Rs.55,939/-(Rs.Fifty Five Thousand Nine Hundred Thirty Nine only) to the complainant with interest @ 8% PA from the date of complaint to till realization.

The OP is also directed to pay compensation of Rs.8,000-00 (Rs.Eight Thousand only) and litigation cost of Rs.8,000-00(Rs. Eight Thousand only) to the complainant.

The OP is further directed to comply the above order within 45 days from the date of receipt/knowledge of this order.