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

DATED 30^TH DAY OF SEPTEMBER 2022

ORDER

SRI.K.S.BILAGI, PRESIDENT

1.         The complaint came to be admitted against the OP1 and 2 only vide order dated 05.03.2022.
2. This complaint is filed by the complainant under section 35 of C.P.Act 2019 (herein after referred as “Act”) against the OPs for the following reliefs.

1. Direct the OPs to pay an amount of Rs.5,50,000/- to the complainant as per the claim.
2. Direct the OPs to pay an amount of Rs.2,00,000/- to the complainant as compensation towards the suffering and mental agony by not disbursing the above said policy amount in due course.
3. Pass such other order.

3. The brief case of the complaint is as follows:

The complainant got admitted in the hospital of OP3 on 24.04.2021 for cough, expectoration, tiredness, difficulty in breathing and diagnosed as Covid-19 and was discharged on 05.05.2021 after payment of Rs.5,50,000/-.The complainant had submitted the claim petition with OP1 claiming the amount, but OP1 not only repudiated the claim but issued another letter.Thereafter, the complainant has obtained clarification letter from OP3 on 28.09.2021 with regard to oxygen saturation at the time of admission was 88% and after treatment oxygen level improved at 91%.However the OP1 repudiated the claim by letter dated 15.11.2021 stating that IP number is mismatching between admission register and IP register, clinical picture between Indoor case record and discharge summary are not matching, however writing note in admission register, indoor case records appeared to be tampered in multiple places and hospital is excluded provider.

4. Complainant contends that OP2 repudiated the claim with malafide intention to cheat the complainant on false grounds.  Infact the complainant has spent amount which is legally entitled from OP2. The repudiation of claim by the OP1 is illegal.  Hence this complaint.
5. In response to the notice, OP1 only appears and fails to file version.  Despite receipt of notice OP2 failed to appear before this commission and OP2 has been placed exparte. Despite sufficient opportunity granted to OP1, OP1 fails to file version.
6. The complainant files affidavit evidence and relies on 11 documents.  Arguments of advocate for complainant was only heard. No argument is advanced on behalf of the OP1. Perused the records.
7. The points that would arise for our consideration are as under:-

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

8. Our answer to the above points are as under:

       Point No.1 :- Affirmative

      Point No.2 :- Affirmative in part

       Point No.3:- As per the final order.            

                                REASONS

9. Point No.1 and 2:     It is proper to refer the admitted facts before touching the controversies between the parties.  It is proved from the allegation made in the complaint, affidavit evidence of complainant and Ex.P1 and P2  that on the date of admission of complaint in OP3 hospital, the policy of the complainant was in force from 21.11.2020 till 20.11.2021.  The total sum inured was Rs.5,00,000/- + bonus of R.2,10,000/-.
10. It is admitted and proved from Ex.P3, P4 and P5 that the complainant was admitted in OP3 hospital on 24.04.2021 at 10.30 pm and was discharged on 05.05.2021 at 4.05 pm.  Ex.P3 indicates that complainant was admitted at 10.30 PM, but discharged summary indicates the complainant was admitted at 11 pm.  These two hours discrepancies cannot be the ground to reject the claim of the complainant.
11. Ex.P3 indicates that at the time of admission on 24.04.2021 at 10.30 pm SOP 2 level of the complainant was 93%.  Whereas Ex.P5 discharge summary issued on 05.05.2021 indicates that pulse rate was 88 BPM.  Even though claim of the complainant repudiated by the OP1 as per Ex.P8 dated 26.08.2021 and Ex.P10 dated 15.11.2021, but OP3 issued Ex.P9 letter dated 28.09.2021 stating that at the time of admission oxygen saturation was 88% and after the treatment oxygen improved at 93%.  Despite such explanation the OP1 proceeded to reject the claim of the complainant.  In view of the explanation offered by the OP3, rejection of claim of the complainant due to difference in oxygen saturation level at the time of admission and subsequently it was improved to 93% is not proper.
12. After receipt of Ex.P10 dated 15.11.2021 repudiation letter the complainant has filed this complaint and made reference of this letter at para 7 of his complaint. But the complainant only contends that OP1 with a malafide intention and rejected the legal claim on false grounds. But complainant has not specifically denied the reason stated by OP1 in second repudiation letter Ex.P10 dated 15.11.2021. It is also relevant to note that even though OP1 appeared through his counsel, but failed to file version and also failed to produce the original record submitted by the complainant to enable this commission to accept the say of OP1 in repudiation letter dated 15.11.2021.
13. It is also relevant to note that the complainant claim refund of R.5,50,000/- and compensation of Rs.2,00,000/-.  On 12.05.2022 the Advocate for OP1 filed a Memo that OP was ready to settle the claim to the extent of Rs.3,19,441/- but no explanation is offered in the memo how the claim was reduced from R.5,50,000/- to Rs.3,19,441/-.  In the absence of no explanation for rejection of the claim amount, we incline to accept the claim of the complainant to the tune of Rs.5,50,000/-.  The initially burden lies on the OP1 to prove that out of Rs.5,50,000/- the complainant is entitled only Rs.3,19,441/-.  It is true that OP1 deals with public money.  It does not mean that OP1 can reduce the claim without any proper explanation.  It is proved from Ex.P11 set of bill that the complainant has really spent Rs.5,50,000/-.  Under such circumstances, the complainant is entitled to Rs.5,50,000/- reimbursement towards medical expenses.  The complainant claims Rs.2,00,000/- as compensation, but he has not offered any supporting reason how he is entitled to Rs.2,00,000/- as compensation.
14. The complainant made payment under Ex.P11 on 05.05.2021.  The claim of the complainant came to be rejected by OP1 under Ex.P8 dated 26.08.2021 and 15.11.2021.  In the absence of any supporting reasons to claim Rs.2,00,000/- as compensation, the complainant is not entitled to compensation to the tune of Rs.2,00,000/-.  The repudiation of claim of the complainant on 26.08.2021 on 15.11.2021 is not correct.  Therefore, the complainant is entitled to interest at 8% on Rs.5,50,000/- from 26.08.2021 till realization in the form of compensation.  Accordingly we answer point NO.1 and 2.
15. POINT NO.3: Having regard to the discussion made on point No.1 and 2, the complaint requires to be allowed in part. OP1 alone is liable to reimburse Rs.5,50,000/- with interest at 8% p.a., from 26.08.2021 till realization and cost of litigation of Rs.10,000/-.  The complaint against OP2 requires to be dismissed. We proceed to pass the following;

O R D E R

1. Complaint against OP1 is allowed in part.
2. Complaint against OP2 is dismissed.
3. OP1 shall reimburse Rs.5,50,000/- to the complainant with interest at 8% p.a., from 26.08.2021 till realization and pay cost of litigation of Rs.10,000/-.
4. OP1 shall comply this order within 60 days from this date.
5. Furnish the copy of this order to the complainant and OP1 and return the extra pleading and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 29^th day of September, 2022)

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

Documents produced by the representative of opposite party :  

NIL

HAV*