By Sri. Mohamed Ismayil.C.V, Member
1.The case of the complainant is in brief :-
The complainant had availed a Health Insurance Policy from the opposite party covering for a sum of Rs. 2,00,000/- and P/181311/01/2021/007388 was the policy number. The above said policy was valid from 24/03/2021 to 23/03/2022. It is stated in the complaint that he had availed the above said policy since the year 2010 in order to secure financial support for the treatment of diseases, if any, affected. According to the complainant, the opposite party had made believe him that the Insurance Coverage would be benefited in the circumstances where any diseases was detected to him. It is stated in the complaint that the complainant had undergone treatment for multiple myeloma and incurred huge expenses in hospital. It is alleged by the complainant that the opposite party had made reimbursement of a total of Rs. 83,858/- without considering claim application properly. It is further alleged that the opposite party rejected the claim in an arbitrary manner and acted against the terms of policy. The amount paid by the opposite party was in two instalments of Rs. 50,000/- and Rs. 33,858/-. The act of the opposite party caused mental agony and hardship to the complainant and he also suffered financial loss. So the complainant approached the Commission alleging deficiency in service against the opposite party. The complainant prayed for a direction to the opposite party to reimburse the balance amount of insurance coverage after deducting Rs. 83,858/- which was already given by the opposite party. The complainant also prayed for a direction to the opposite party to pay compensation of Rs. 50,000/- for the sufferings of mental agony and hardship due to the act of the opposite party.
2. The complaint is admitted and issued notice to the opposite party. The opposite party appeared before the Commission and filed version.
3. In the version, the opposite party denied the statements of the complainant and alleged that complainant was filed with ulterior motive and for making illegal gains. According to the opposite party, the complaint is not maintainable as there was no cause of action arisen in the complaint. It is averred that the claim of the complainant was no repudiated so far by the opposite party. It is admitted by the opposite party that the complainant had availed Mediclassic Insurance Policy on 30/07/2010 for a sum insured of Rs. 2,00,000/- and the same has been renewed up to 23/03/2022 vide policy number P/181311/01/2021/007388. The complainant was well aware of the terms and conditions of policy. It is also admitted by the opposite party that the complainant had submitted two claims numbered as CIR/2022/181311/3745073 and CIR/2022/181311/3753461. The claim number CIR/2022/181311/3745073 was related to admission in Christian medical College Hospital, Vellore from 03/01/2022 to 18/01/2022 and the complainant was diagnosed with multiple Myeloma. The complainant submitted claim form along with bills for an amount of Rs. 6,65,986/- after his discharge. The discharge summary showed that he had undergone stem cell transplantation. It is contended by the opposite party that as per insurance coverage for modern treatment coverage clause J of the policy, the expenses refundable during the entire policy period for stem cell therapy is limited to Rs. 50,000/- for the sum insured of Rs. 2,00,000/-. So the opposite party paid Rs. 50,000/- to the complainant and not liable to pay further amount to the complainant. As per claim number CIR/2022/181311/3753461, the complainant was admitted in the hospital on 18/01/2022 and provisionally admitted with multiple myeloma post transplant care. It is further stated by the opposite party that initially the opposite party authorized an amount of Rs. 1,00,000/- for cashless hospitalization and same was informed the hospital on 18/01/2022. But the hospital forwarded final bill of Rs. 56,791/- along with discharge summary. On verification it was seen that the complainant had undergone stem cell transplantation. But as per policy, the opposite party was liable to pay Rs. 50,000/- only and the same was already paid in the previous claim. So after deducting the expenses incurred for stem cell transplantation the opposite party processed the claim and it came to tune of Rs. 33,858/- as payable under the policy coverage. After the approval same was informed the hospital vide letter dated 21/01/2022. Prior to final authorization, the opposite party again processed the claim and found it that there was a discount of Rs. 7,174/- by the hospital and hence the opposite party approved the claim for Rs. 26,684/- and informed the hospital on 21/01/2022. The complainant had discharged from the hospital on 21/01/2022 and thereafter submitted discharge summary and bills for balance of cashless. It is stated by the opposite party that the complainant did not produce prescription for the bills, cash paid receipts or paid seal and not properly filled the claim. So a query letter was sent on 14/03/2022 directly to submit documents. But the complainant did not turned up. It is alleged that the complainant filed this complaint without submitting necessary documents before the opposite party. As per terms and conditions of the policy, the entire expenses for the stem cell transplant is limited. It is denied by the opposite party that the complainant had contacted the representative of the opposite party. It is also alleged by the opposite party that the complainant had suppressed the matter of the query letter in the complaint. According to the opposite party as per condition No.VI (2) of the policy, claim will be decided on merits only if the insured person shall obtain and furnish with all original documents upon which a claim is based and shall also give the opposite party such additional information and assistance might have required to process the claim. The opposite party stated that there was no deficiency in service on the part of the opposite party and complainant is not entitled for any relief.
4. The complainant and the opposite party are filed affidavits in lieu of evidence. The complainant also produced documents and marked them as Ext. A1 to A8 documents. Ext. A1 document is the copy of discharge summary dated 18/01/2022 issued from CMC, Vellore. Ext. A2 document is the copy of consolidated receipts dated 03/02/2022 issued by CMC, Vellore for a period from 03/01/2022 to 18/01/2022. Ext. A3 document is the copy of query letter dated 19/01/2022 issued by the opposite party. Ext. A4 document is the copy of letter showing the approval of claim amount. Ext.A5 document is the copy of bill assessment sheet issued by the opposite party in connection with CIR/2022/181311/375073. Ext. A6 document is the copy of letter dated 25/02/2021 issued by the opposite party. Ext. A7 document is the copy of Tax Certificate under Section 80 D of Income Tax Act,1961 issued by the opposite party. Ext. A8 document is the copy of receipt issued by the opposite party in favour of the complainant. The documents produced by the opposite party are marked as Ext. B1 to B11. Ext.B1 document is the copy of policy schedule and conditions of the insurance policy subscribed by the complainant. Ext. B2 document is the copy of discharge summary dated 18/01/2022 issued from CMC, Vellore. Ext.B3 document is the copy of bill assessment sheet in CIR/2022/181311/ 3745073. Ext. B4 document is the copy of request for cashless hospitalization from CMC, Vellore. Ext. B5 document is the copy of cashless authorization letter dated 18/01/2022 issued by the opposite party in CIR/2022/181311/3753461. Ext. B6 document is the copy of discharge summary issued by CMC, Vellore for the period from 18/01/2022 to 21/01/2022 in CIR/2022/181311/3753461. Ext. B7 document is the copy of discharge bill issued by CMC, Vellore in CIR/2022/181311/3753461. Ext. B8 document is the copy of revision of authorized amount dated 21/01/2022 issued by the opposite party in CIR/2022/181311/3753461. Ext. B9 document is the copy of revision authorized amount dated 21/01/2022 issued by the opposite party in CIR/2022/181311/3753461. Ext.B10 document is the copy of claim form in CIR/2022/ 181311/3753461. Ext. B11 document is the copy of query letter dated 14/03/2022 issued by the opposite party in CIR/2022/181311/3753461.
5. Heard both sides in detail. Perused documents and affidavits thoroughly . The points arisen for the consideration are:
- Whether the opposite party has committed deficiency in service.
- Relief and cost.
6. Point No.(1) and (2) :-
It is averred by the complainant that he had availed a Health Insurance Policy coverage from the opposite party believing that there would be financial support in case of treatment for any ailment is affected in future. The complainant produced coy of policy schedule issued by the opposite party and same is marked as Ext. A7 document. It is further averred that the policy coverage was valid from 24/03/2021 to 23/03/2022 and insured sum is Rs. 2,00,000/-. The opposite party admitted the facts of subscription of policy. The complainant stated that he had undergone treatment for multiple myeloma and incurred huge expenses. It was also stated by the complainant that the opposite party reimbursed only Rs. 83,858/- and balance amount was remained unpaid. It is contended that the opposite party is liable to reimburse the balance amount of insured sum as per policy condition. The complainant produced discharge summary issued from the Christian Medical College, Vellore and marked it as Ext. A1 document. The opposite party also produced same document marked as Ext. B2 document Ext. A1 document shows that the complainant was admitted in the hospital from 03/01/2022 to 18/01/2022 and undergone treatment for multiple myeloma. It is averred by the complainant that he had spent a huge amount for his treatment in the hospital. The complainant produced consolidated receipt dated 03/02/2022 issued by the hospital authority and same is marked as Ext. A2 document. Ext. A2 document would show the quantum of amount spent for treatment. It is stated in the affidavit of the complainant that he had incurred expenses of Rs. 6,65,986/- (Rupee Six lakh sixty five thousand nine hundred and eighty six only) in the hospital for his treatment. It is alleged by the complainant that he had repeatedly contacted the opposite party to get reimbursed the balance of insured sum, but did not heed up. The complainant had submitted relevant documents pertaining to his treatment and transaction made with the opposite party and those documents are marked as Ext. A3 to Ext. A8 document. The opposite party did not contradict over the documents produced by the complainant.
7. But on the other hand, the opposite party contended that there was no
deficiency of service on the part of the opposite party and the complainant was not entitled for any amount as per condition of the policy. In addition, the opposite party stated that as per insurance coverage for modern treatment coverage clause of the policy, the expenses refundable during the entire policy period for Stem Cell therapy is limited to Rs. 50,000/- for the sum insured of Rs. 2,00,000/-. The opposite party produced copy of policy schedule and condition before the Commission and same is marked as Ext. B1 document. In connection with the evidence of the opposite party, the Commission also marked some other documents produced by the opposite party. According to the version of the opposite party, the complainant had submitted two claims before the opposite party for reimbursement of expenses incurred for his treatment under policy coverage. The claim number CIR/2022/181311/3745073 is related to the admission in Christian Medical College , Vellore from 03/01/2022 to 18/01/2022 and he was diagnosed with multiple myeloma. The bill assessment sheet in connection with above stated claim was produced by the opposite party and marked as Ext. B3 document. Ext. B3 document spells out that Rs. 50,000/- was the payable amount as per policy condition. The opposite party further stated that the complainant had submitted another claim numbered as CIR/2022/181311/3753461 in which the opposite party received a request for cashless hospitalisation from CMC, Vellore stating that complainant was admitted on 18/01/2022 and provisionally diagnosed with multiple myeloma post transplant care. The opposite party produced cashless Authorisation letter dated 18/01/2022 before the Commission and same is marked as Ext. B5 document. Ext. B5 document would show that total estimated amount for the treatment was fixed to the tune of Rs. 3,00,000/- and initial authorised amount was provisionally fixed as Rs. 1,00,000/-. The opposite party produced revision of authorised amount dated 21/01/2022 and same is marked as Ext. B8 document. Ext. B8 document would show that the final approved amount is Rs. 33,858/-by the opposite party. The opposite party produced copy of discharge summary showing the treatment of the complainant and it is marked as Ext. B6 document. The copy of discharge bill issued by the hospital authority in CIR/2022/181311/3753461 is marked as Ext. B7 document.
8. The argument of the opposite party is that no liability could be cast upon them as clause of the conditions stand in their favour. But the Commission hold the view that the complainant is eligible for the total amount of insured sum as per policy. It can be seen that a huge amount was spent for the treatment of the complainant. It is stated by the complainant that he secured policy coverage from the opposite party in order to meet treatment expenses of diseases, if any affected. The Commission also find that the complainant had been subscribing insurance policy coverage since the year 2010 uninterruptedly. Here, the complainant had under gone a treatment of stem cell transplantation for curing multiple myeloma. Definitely there will be ancillary expenses for any kind of treatment. After fixing the insured sum for Rs. 2,00,000/-, it is quite arbitrary and unreasonable on the part of the opposite party to create a ceiling of amount for treatment. Even though it was alleged by the opposite party that the complainant had not submitted required documents along with claim form but same cannot be considered as it lacked evidence. It was contended by the opposite party that there was no cause of action rised to file this complaint as the claim was not repudiated. The Commission find that there was no bar to approach the Commission without repudiation of claim. The cause of action began to run from the very moment of denial of entire insured sum. The complainant had entered into insurance contract with the opposite party intended to cover any contingency that might happen in future and so he paid premium. But the contract was prepared by the opposite party, the insurer, having a standard format upon which the complainant was made to sign. The complainant had very little option or choice to negotiate the terms and conditions of the contract. The opposite party was in a dominant position to dictate its own terms, burdening the complainant either to accept it or abandon it. So the above discussed facts reveal that the opposite party committed deficiency in service towards the opposite party in disbursing the insured amount to the complainant . The act of the opposite party caused mental agony and hardship to the complainant especially in a situation where in the complainant was fighting to overcome the disease. It is admitted by the complainant that he had received a total of Rs. 83,858/- from the opposite party and claimed the balance of insured sum. So the Commission find that the opposite party is liable to reimburse Rs. 1,16,142/- (Rupees One lakh sixteen thousand one hundred and fourty two only) as the balance insured sum of Rs. 2,00,000/-. Hence the Commission allows the complainant in the following manner:-
- The opposite party is directed to pay Rs. 1,16,142/- (Rupees One lakh sixteen thousand one hundred and fourty two only) to the complainant as the balance amount of insured sum with interest 9% per annum from 21/01/2022, the date of discharge from the hospital.
- The opposite party is directed to pay Rs. 50,000/-(Rupees Fifty thousand only) to the complainant as compensation for the sufferings of mental agony and hardship due to the deficiency in service on the part of the opposite party.
- The opposite party is directed to pay Rs. 10,000/-(Rupees Ten thousand only) as the cost of the proceedings to the complainant .
The opposite party shall comply this order within 30 days from the date of receipt of copy of this order otherwise the entire amount shall carry 9% interest per annum from the date of the order to till realisation.
Dated this 31st day of July, 2023.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Ext.A1to A8
Ext. A1 : Document is the copy of discharge summary dated 18/01/2022 issued from
CMC, Vellore.
Ext. A2: Document is the copy of consolidated receipts dated 03/02/2022 issued by
CMC, Vellore for a period from 03/01/2022 to 18/01/2022.
Ext. A3 : Document is the copy of query letter dated 19/01/2022 issued by the
opposite party.
Ext. A4: Document is the copy of letter showing the approval of claim amount.
Ext.A5 : Document is the copy of bill assessment sheet issued by the opposite party
in connection with CIR/2022/181311/375073.
Ext. A6: Document is the copy of letter dated 25/02/2021 issued by the opposite
party.
Ext. A7: Document is the copy of Tax Certificate under Section 80 D of Income Tax
Act,1961 issued by the opposite party.
Ext. A8: Document is the copy of receipt issued by the opposite party in favour of the
complainant.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1 to B11
Ext.B1: Document is the copy of Bill document is the copy of policy schedule and
conditions subscribed by the complainant.
Ext. B2: Document is the copy of discharge summary dated 18/01/2022 issued from
CMC, Vellore.
Ext.B3: Document is the copy of bill assessment sheet in CIR/2022/181311/ 3745073. Ext.B4: Document is the copy of request for cashless hospitalization from CMC,
Vellore.
Ext.B5: Document is the copy of cashless authorization letter dated 18/01/2022
issued by the opposite party in CIR/2022/181311/3753461.
Ext.A6: Document is the copy of discharge summary issued by CMC, Vellore for the
period of 18/01/2022 to 21/01/2022 in CIR/2022/181311/3753461.
Ext. B7: Document is the copy of discharge bill issued by CMC, Vellore in CIR/2022/
181311/ 3753461.
Ext. B8: Document is the copy of revision of authorized amount dated 21/01/2022
issued by the opposite party in CIR/2022/181311/3753461.
Ext. B9: Document is the copy of revision authorized amount dated 21/01/2022
issued by the opposite party in CIR/2022/181311/3753461.
Ext.B10: Document is the copy of claim form in CIR/2022/181311/3753461.
Ext.B11: Document is the copy of query letter dated 14/03/2022 issued by the
opposite party in CIR/2022/181311/3753461.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
