BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 22^ND DAY OF NOVEMBER 2022

ORDER

SMT.M.SHOBHA, PRESIDENT

1. The complaint has been filed under Section 35 of C.P.Act (hereinafter referred as an Act) against the OP for the following reliefs against the OP:-

1. To pay the reimbursement claim amount / medical expenses, damages, compensation etc., to the tune of total sum of Rs.2,00,000/- with interest.
2. To grant such other relief/s in the interest of justice and equity.

2. The case set up by the complainant in brief is as under:-

The complainant had obtained the health insurance policy from 16.08.2018 and the policy was issued on the same day in favour of the complainant and her husband Sri.Raghu and minor child Ruthwik.  The complainant has paid Rs.11,506/- for the renewal of the policy.

3. The complainant had admitted to Aditi Hospital, Gandhi Square, New pet, Anekal on 12.05.2021 and she was discharged on 16.05.2021.  The complainant was admitted to the hospital due to the complaint of breathlessness cough and fever.  After the investigation done in the above hospital it came to know that the complainant was covid 19 positive.  After taking treatment for six days she was discharged from the hospital in a stable condition.  The total medical expenditure bill was Rs.81,601/-.
4. The complainant has approached the OP for the reimbursement of the expenses incurred due to the treatment.  She has also produced all the related documents to the OP to get the hospitalization expenses.  The claim was made by the complainant on 15.06.2021, but the OP have denied the request of the complainant saying vague and hazy statements, that the complainant has not been admitted to the hospitals and not taken any treatment.  The statements made by the OP and his authority agents are against the terms and conditions of the insurance policy.  In view of this, the complainant has suffered irreparable loss and the act of the OP amounts to deficiency of service and unfair trade practice.
5. It is further case of the complainant that the OP has intentionally failed to consider the claim made by the complainant.  It is the bounden duty on the OP to reimburse and pay the claim amount. The non co-operation, failure of refusal to pay the claim amount on technical /silly reason is not acceptable at any stretch, either in law or on facts.  The complainant has issued a legal notice on 14.01.2022.  Inspite of the receipt of the legal notice the OP has neither complied with the just and legal demands of the complainant or come forward to pay the claim amount. Hence the complainant has filed this complaint.
6. In response to the notice, OP appears and fails to file the version.
7. The complainant has filed her affidavit evidence and relies on 06 documents.  OP has neither adduced any evidence nor submitted arguments.
8. Heard the arguments of advocate for the complainant only.  No oral or written argument is advanced on behalf of OP.  Perused the written arguments of the complainant.

9. The following points arise for our consideration as are:-

1. Whether the complainant proves deficiency of service on the part of OP?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

10.       Our answers to the above points are as under:

       Point No.1:  Affirmative

      Point No.2: Affirmative in part

      Point No.3: As per final orders

REASONS

11.    Point No.1 AND 2: Perused the complaint evidence of the complainant and the written arguments filed by the complainant.  Even though the OP has appeared before this Commission through their counsel have failed to file the version.  They have neither adduced any evidence nor submitted any arguments in support of their contention.  The evidence and the allegations made by the complainant remained unchallenged.  

12.     The complainant has obtained the health insurance policy from the OP on 16.08.2018 by paying premium amount of Rs.11,506/-.  She has produced copy of the insurance policy and it clearly discloses that the basic floater sum insured was Rs.5,00,000/- and the policy was in force from 31.08.2020 till 30.08.2021 and the recharge benefit was given for Rs.1,50,000/-.  The treatment taken for covid 19 is not excluded in the policy.  

13.     In support of her contention the complainant filed her affidavit evidence and relied on six documents.  Ex.P1 and P3 are the receipts issued by the Aditi Hospital towards inpatient bill.  They have collected Rs.81,601/- for the treatment taken by the complainant from 11.05.2021 till 16.05.2021 for covid 19 infection.  Ex.P2 is the discharge summary and it clearly discloses that the complainant was admitted to that hospital with complaints of general weakness cough and other body ach etc., from 10 days and later she was diagnosed as covid 19 infection and she was treated for the same. Ex.P4 is the legal notice issued by the complainant counsel to the OP.  Ex.P5 and P6 are all the postal receipts and acknowledgement for having served the notice to the OP1 and 2.  

14.     The complainant after taking treatment at Aditi Hospital was discharged on 16.05.2021.  After that she has send a legal notice to the OP on 14.01.2022 and the same was served on the OP1 and 2.  Inspite of the service of the notice the OP neither paid the amount nor issued any reply for not entertaining the claim.  

15.     As per the averments made in the legal notice Ex.P4 the claim was made by the complainant by furnishing all the documents and bills to the OP on 15.06.2021.  According to the complainant the OP after receiving the claim application have given vague and hasty statements stating that the complainant has not admitted to the hospital and she has not taken any treatment. The complainant has neither produced the copy of the claim application submitted to the OP. Even after receiving the claim application from the complainant the OP have neither repudiated the claim nor entertain the claim. They have kept quite from 15.06.2021 till the filing of the complaint.  Even after filing of the complaint by the complainant and after service of the notice and after appearance of the OP through their counsel have neither filed their version nor adduced any evidence.  Under these circumstances the evidence of the complainant and documents Ex.P1 to P6 produced by the complainant remained unchallenged.

16.     It is clear from the documentary evidence Ex.P1 to P6 that the complainant has got the insurance policy from the OP and the sum insured was Rs.5,00,000/- and it was in force as on the date of taking treatment by the complainant from 11.05.2021 to 16.05.2021.  On perusal of the copy of the policy produced by the complainant it is clear that the treatment for covid is not excluded in the policy.  Under these circumstances the OP is bound to pay the claim made by the complainant unless it is repudiated by them on any other grounds.  

17.     The OP after issue of the insurance policy has to entertain the claim or to repudiate the claim and they cannot keep quite and maintain silence without paying the amount.  The OP have not paid the claim amount made by the complainant even though the complainant is entitled for the medical expenses and also other charges during hospitalization.  

18.     The receipt issued by the hospital authorities as per Ex.P1 clearly discloses that the complainant has paid Rs.81,601/- at the time of discharge from the office.  The complainant has also produced the copy of the medicine bills as the original was sent to the OP along with the claim application.  The non entertainment of the claim made by the complainant by the OP amounts to deficiency of service and also unfair trade practice.  Hence the complainant is entitled for an amount of Rs.81,601/- towards medical expenses.

19.     The complainant has made a total claim of Rs.2,00,000/- including medical expenses damages, compensation and litigation expenses.  When the OP have failed to pay the claim amount made by the complainant, the complainant has suffered mental harassment and also financial loss.  In view of the negligent attitude of the OP the complainant was forced to approach this Commission by filing this complaint even though she has got a valid insurance policy and paid the premium amount and the policy was in force during the treatment period.  Under these circumstances the complainant is also entitled for litigation expenses of Rs.10,000/- and damages and compensation of Rs.30,000/-.   Hence we answer point No.1 in affirmative and Point No.2 party in the affirmative.

20.     Point No.3:- In view the discussion referred above, OP is directed to pay Rs.81,601/- towards medical expenses with interest at the rate of 10% p.a., from the date of complaint till realization.  The OP is further directed to pay compensation of Rs.30,000/- and litigation expenses of Rs.10,000/- to the complainant within 60 days from the date of this order.

O R D E R

1. The complaint is allowed in part.
2. OP is directed to pay Rs.81,601/- towards medical expenses with interest at the rate of 10% p.a., from the date of complaint till realization.
3. OP is further directed to pay compensation of Rs.30,000/- and litigation expenses of Rs.10,000/- to the complainant.
4. The OP shall comply this order within 60 days from this date, failing which the OP shall pay interest at 12% p.a. after expiry of 60 days on Rs.81,601/- till final payment.
5. Furnish the copy of this order and return the extra pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 22^ND day of NOVEMBER, 2022)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party – R.W.1;

• NIL -