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

DATED 28TH DAY OF DECEMBER 2022

ORDER

SRI.M.SHOBHA, PRESIDENT

1. The  complainant  has filed this complaint against the Opposite parties  for reliefs

To direct the OP to pay a sum of Rs.1,34,750/- together with interest at the rate of 18% p.a. and cost of the complaint and  such other reliefs.

2.  The case of the complainant is that:

The complainant filed this complaint stating that he has taken health insurance policy from OP on 23.06.2020 and it was valid from 23.06.2020 to 22.06.2021 with liable to indemnify the complainant with regard to entire medical expenses.

The complainant was admitted to Appolo hospital on 03.05.2021 due to Corona Pandemic disease with serious condition where he was treated as inpatient and discharged on 09.05.2021. The hospital has charged for medical treatment, medicines, bed charges etc. an amount of Rs.1,21,750/-. The complainant has informed the OP to pay and indemnify the hospital bill, but the OP has paid only Rs.20,000/- and not paid balance amount Rs.1,01,750/-.

The complainant contacted the OP for several times demanding the payment of the balance amount. When the OP shown negligence and not paid any amount, he got issued legal notice  to OP on 27.12.2021 for demanding the payment of balance amount. In spite of service of the notice the OP neither complied nor issued any reply. Even though the policy was in force during the treatment period the OP failed to pay the amount and there by the OP has played fraud and deficiency of service. In view of this the complainant has suffered mental agony, financial loss apart from liability to pay balance hospital bill amount with interest.  Hence, the complainant has filed this complaint.

3. After service of notice, OP has appeared before this commission through their counsel, but not filed version.

4. The complainant in order to prove his contentions has  filed his affidavit evidence and relied on Ex.P1 to P7.

5. We heard the arguments of the complainant and perused written arguments.

6. The following points do arise for our consideration are as under:-

1. Whether there is deficiency in service on the part of the OP?
2. Whether the complainant is entitled for the reliefs as sought for?
3. What order?

7. 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

8. Point Nos.1 and 2:. These two points are interrelated and hence they have  taken up for common discussion.

9. The complainant has filed his affidavit evidence by reiterating all the allegations made in the complaint as stated above.

10. He has relied on Ex.P1 to P7. Ex.P1 is the inpatient bill dt.09.05.2021, Ex.P2 is the medical report of the complainant issued by Appolo hospital, Ex.P3 is the copy of the legal notice, Ex.P4 is postal receipt and Ex.P5 is postal tract consignment, Ex.P6 is copy of the insurance policy issued by the OP and  Ex.P7 is the advance premium receipt issued by the OP for having received the premium amount of Rs.10,453/-.

11. It is clear from Ex.P6 the insurance policy that the complainant has taken insurance policy from OP and it is comprehensive insurance policy and the insured amount is Rs.5,00,000/- and it is valid from 23.06.2020 up to 22.06.2021. The Ex.P6 is a health insurance  policy. On perusal of terms and conditions in the policy it is clear that the treatment taken for Covid is  not at all excluded in the policy. The Ex.P7 i.e. advance premium receipt issued by the OP clearly discloses that they have collected the premium of Rs. 10,453/- from the complainant on 23.06.2020.

12. It is also clear from the discharge summary issued by the hospital that the complainant was admitted to the hospital on 03.05.2021 and he was discharged on 09.05.2021. The complainant was treated for Covid-19(RT-PCR)-positive Lower respiratory tract infection. It is also clear from the discharge summary that the complainant was treated with oxygen, antiviral  (REMDESERVIR) IV Antibiotics, steroids, PPI and supportive care. The complainant was discharged after he was improved clinically and maintained saturation of oxygen 95% on room air with advise to continue the medicines and for review and to admit in case of emergency.

13. Ex.P3, the legal notice issued to the OP clearly discloses that even though the complainant has contacted OP for balance payment of medical bills the OP has not turned up. They have neither complied the request of the complainant nor issued reply notice. The OP has not at all repudiated the claim by giving proper reasons and they simply keeping quite without responding to the request made by the complainant.

14. The OP cannot be kept quite after issue of the policy and after collecting the premium amount and the policy was in force when the complainant was admitted to hospital and taken treatment as inpatient. There is no terms and conditions in the policy that the treatment taken by the complainant for Covid-19 is a excluded from the policy and it is not payable. The silence of the OP can be treated as repudiation of the claim made by the complainant. The refusal to pay the amount when the policy was in force amounts to deficiency of service and unfair trade practice. Under these circumstances the complainant is entitled for the medical claim and also for damages for mental agony and financial loss and litigation expenses. Hence, we answer point no.1 in the affirmative and Point No.2 affirmative in part.  

15. Point no.3:-.  In view of the above discussions, the complaint is liable to be allowed in part and complainant is entitled for Rs.1,01,750/- with interest at the rate of 10% p.a. from the date of complaint. The complainant is also entitled for compensation of Rs.30,000/- for the financial loss and also mental agony suffered by him. The complainant is also entitled for litigation expenses of Rs.10,000/-. Accordingly, we proceed to pass the following 

O R D E R

1. The complaint is allowed in part.
2. The OP is directed to pay Rs.1,01,750/- with 10% p.a. interest from the date of complaint till realization.
3. OP is further directed to pay compensation of Rs.30,000/-towards financial loss, mental agony  suffered by the complainant and Rs.10,000/- as litigation expenses.
4. OP is further directed to pay entire amount within 60 days from the date of this order, if the OP failed to refund the amount, the amount of  Rs.1,01,750/- will carry interest at 12% p.a. after expiry of 60 days  till realization of the amount.
5. Furnish the copy of this order to both the parties, and return the spare pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 28^th  day of December, 2022)

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

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

SKA