By Sri. Mohamed Ismayil.C.V, Member
The complainant stated his grievance as follows:-
1. The complainant averred that he had availed Star comprehensive Insurance policy from the opposite party since the year 2016. The complainant used to renew the health insurance policy in every year and present policy was valid from 26/07/2020 to 25/07/2021. The present policy number is P/181312/01/2021/001191 and it is covered for Rs.15,00,000/- and additionally for Rs. 15,00,000/- as bonus. According to the complainant, he has availed the above policy to meet the expenses of treatment of any kind of disease if it was affected. On 09/05/2021, the complainant had affected with Covid-19 pandemic and admitted in Sacred Heart Hospital , Manimooli and treated as inpatient. But the condition of the complainant worsened as 90% of the functioning of lungs were damaged. Then on 14/05/2021, the complainant was shifted to Almas Hospital, Kottakkal for advanced treatment by using Ambulance service. The condition of the complainant seriously continued as vital organs are got damaged due to Corona Virus. However the complainant had recovered from Covid-19, disease by undergoing advanced treatment. It is stated by the complainant that due to covid -19 the functioning of vital organs seriously affected. It is described by the complainant that he had undergone treatment of expert doctors, used expensive medicine and also availed Intensive Care Unit facilities to recover from dangerous situation. It is stated in the complaint that a total of Rs.1,85,966/- (Rupees One lakh eighty five thousand nine hundred and sixty six only) incurred for treatment in Almas Hospital, Kottakkal but the opposite party remitted only Rs. 96,295/- (Rupees Ninety six thousand two hundred and ninety five only) in the hospital. The balance amount was paid by the complainant with the help of his relatives and friends. It is averred by the complainant that the opposite party was liable to pay entire amount incurred for the treatment. It is also averred that the complainant incurred Rs. 21,072/- (Rupees Twenty one thousand and seventy two only) for the treatment of Covid -19 in Sacred Heart Hospital , Manimooli, but remitted only Rs. 18,181/- (Rupees Eighteen thousand one hundred and eighty one only) by the opposite party. The opposite party was also withheld from payment of Rs. 2,650/- as the expenses incurred as Ambulance charge. According to the complainant, the opposite party was liable to pay entire amount incurred for his treatment under the insurance policy coverage. It is stated in the complaint that, the act of the opposite party caused much financial constraints and mental agony to the complainant. The complainant was doing beauty parlour business and earning very lower income for his livelihood. Moreover, covid-19 pandemic also caused hurdles to his earnings. The complainant repeatedly contacted the opposite party to get reimbursed the balance amount. But the opposite party cared only a limited extend to reimburse Rs. 3,727/- as post hospital expenses and Rs. 7,000/- as add on benefit. The opposite party did not pay the balance amount as per the terms of the policy coverage so far. It is replied by the opposite party that the expenses incurred for the treatment was excessive than the rate prescribed by the Government. It is contended that the complainant had undergone an expensive treatment for his recovery. The Government fixed rates are applicable only to the cases referred through Government missionary. The treatment undergone by the complainant was very complicated and expensive. The volume of expenses is depending on the nature and seriousness of illness. So the act of the opposite party as discarding the application of the complainant is amount to violation of natural justice. It is alleged by the complainant that, the opposite party has committed deficiency in service towards the complainant. According to the complainant, he is continuing his treatment even after discharge from the hospital as his lungs had sustained 67% damage. It is stated by the complainant that he had made consistent effort to get refunded the amount with his struggling physical condition. So the complainant approached this Commission praying for a direction to reimburse Rs. 92,562/-(Rupees Ninety two thousand five hundred and sixty two only) to the complainant as the balance amount of the hospital expenses incurred in Almas Hospital, Kottakkal and Rs. 2,650/- as the expenses incurred for hiring of Ambulance to go for hospital. In addition, the complainant claimed Rs. 8,00,000/-(Rupees Eight lakh only) as compensation from the opposite party for the sufferings of mental agony, hardship due to the act of the opposite party. The complainant also demanded Rs. 25,000/- from the opposite party as the cost of the proceedings.
2. The complaint is admitted on file and issued to the opposite party. The opposite party entered appearance and filed version.
3. The opposite party denied allegations except those are specifically admitted in the version. According to the opposite party, the complaint is filed with ulterior motive to make unlawful gain and it lack any bonafides. It is admitted by the opposite party that the complainant had availed insurance policy as stated in the complaint. It is also stated that there was no cumulative bonus to the insured in the year 2021-2022 as he had previously claimed benefits under policy coverage. It is contended that at the time of issuance of policy, the complainant was supplied with the terms and conditions of the policy and also explained it. The policy schedule also stated about terms and conditions including warranties and exclusions. According to the opposite party, during the policy period of 2020-2021, the complainant had submitted two claims before the opposite party as CIR/2022/ 181312/2609223 and CIR/2022/181312/2779053. It is clearly averred by the opposite party that CIR/2022/181312/2779053 was submitted in connection with treatment of covid-19 undergone in Sacred Heart Hospital from 09/05/2021 to 14/05/2021. After the discharge, the complainant had submitted claim of Rs. 24,842/- and on verification the opposite party had approved the claim for Rs. 18,181/- (Rupees Eighteen thousand one hundred and eighty one only) . According to the opposite party, the approval was made on the basis of guidelines issued by Government of Kerala and also in accordance with terms of the policy. It is also averred that CIR/2022/181312/2609223 was submitted in connection with treatment undergone in Almas Hospital from 14/05/2021 and discharged on 24/05/2021.The complainant had submitted claim of Rs.1,90,193/- and on verification, the opposite party approved the claim for Rs. 1,07,022/- only. It is contended that there was no delay, or negligence or default in the processing of claims made by the complainant and opposite party had paid the amount legally due to him. According to the opposite party, as per recital clause of the policy, the opposite party will pay the amount of such expenses which are reasonably and necessarily incurred up to the limits indicated. It is averred that the general provisions and exclusion clause applicable are well embodied in contract of insurance made between the parties. The opposite party is not liable to pay the bystander expenses as per the policy. It is contended that the opposite party had procured the claim as per the terms and conditions of the policy and also as per the rate fixed by the Government in Covid -19 cases. The complainant submitted a bill for Rs. 2,650/- in claim No. 2779053 as ambulance charges but the name of the patient was not mentioned therein. It is also contended that the complainant did not suffered mental agony or financial loss. The Government had fixed a rate for Covid-19 cases for both the Government and Private hospitals. The Government has fixed the rate for all the covid cases including the complication cases and to be included in all hospitals. The opposite party did not commit deficiency in service. The opposite party had paid full amount as per policy and the complainant is not entitled for any amount from the opposite party. So the opposite party prayed for dismissal of the complaint.
4. The complainant and the opposite party filed affidavits and also produced documents. The documents produced by the complainant are marked as Ext. A1 to Ext. A4 documents. Ext. A1 document is the insurance policy schedule issued by the opposite party to the complainant. Ext. A2 document is the Bill Assessment Sheet –Member Payment dated 15/07/2021 issued by the opposite party to the complainant in CIR/2022/181312/2609223. Ext. A3 document is the Bill Assessment Sheet –Member Payment issued by the opposite party to the complainant in CIR/2022/ 181312/2779053. Ext. A4 document is the copy of claim form along with treatment records submitted before the opposite party by the complainant. The documents produced by the opposite party are marked as Ext. B1 to Ext.B5 documents. Ext. B1 document is the copy of policy condition issued to the complainant. Ext. B2 document is the copy of discharge summary issued from Sacred Heart Hospital, Manimooli. Ext. B3 document is the copy of bills issued from Sacred Heart Hospital, Manimooli. Ext. B4 document is the copy of discharge summary issued from Almas hospital. Ext. B5 document is the copy of bills issued from Almas hospital. The complainant filed notes of argument also.
5. Heard both sides in detail. The Commission gone through all documents including affidavits filed by the parties in the proceeding. The points arisen for the settlement of consumer disputes are:-
- Whether the opposite party had committed deficiency in service towards the complainant.
- If it is found, what extend relief and cost can be granted.
6. Points No.1 and 2:-
The very case of the complainant was that the opposite party did not paid entire amount as per the claim submitted under Ext. A1 document. According to the complainant he had availed comprehensive health insurance policy coverage from the opposite party since the year 2016 and regularly renewed the same and present policy was valid from 26/07/2020 to 25/07/2021. The policy number is P/181312/01/2021/001191 and copy of the policy schedule is marked as Ext.A1 document. It is averred in the complaint that the complainant was seriously affected by Covid-19 pandemic and he had undergone treatment in Sacred Heart Hospital, Manimooli, due to the transformation into the aggressive form of covid-19, he was shifted to Almas Hospital , Kottakkal for advanced treatment . It is stated in the complaint that a total of Rs. 1,85,966/- incurred as treatment expenses in Almas Hospital to the complainant. It is also stated that Rs. 21,072/- incurred as treatment expenses in Sacred Heart Hospital, Manimooli and also incurred Rs. 2,650/- as expenses for conveyance by using Ambulance. The complainant stated that two claims were submitted before the opposite party under Ext. A1 document, but the opposite party did not pay entire claim amount to the complainant. The complainant produced copy of claim form along with treatment records and those are marked as Ext.A4 documents. The complainant produced Bill Assessment Sheet-Member Payment issued by the opposite party to him in claim No.CIR/2022/181312/ 2609223 and same is marked as Ext. A2 document. The complainant also produced Bill Assessment Sheet-Member Payment issued by the opposite party to him in claim No. CIR/2022/181312/2779053 and same is marked as Ext.A3 document. The complainant challenged the disbursal of amount done by the opposite party and stood for entire claim amount.
7. The opposite party admitted the policy coverage under Ext. A1 document. It is also admitted by the opposite party that the complainant had submitted two claims as stated in the complaint. According to the opposite party, the approval of claims were made on the basis of guidelines issued by the Government of Kerala and also on the basis of terms and conditions of the policy coverage. The opposite party also contended that the complainant was eligible for the amount under the recital clause of the policy which are reasonably incurred up to the limits indicated therein. It is also averred by the opposite party that the opposite party had paid full amount as per policy and complainant was not entitled for further payment. The opposite party produced copy of policy condition before the Commission and same is marked as Ext. B1 document. The opposite party produced discharge summary issued from Sacred Heart Hospital, Manimooli and same is marked as Ext. B2 document. The bills issued from the above Sacred Heart Hospital is marked as Ext. B3 document. The opposite party produced discharge summary issued from Almas Hospital and marked it as Ext. B4 document. The bills of Almas Hospital are produced by the opposite party and marked as Ext. B5 document.
8. The complainant has claimed Rs. 2,650/- from the opposite party as the expenses incurred for using ambulance service. But it is contended by the opposite party that the ambulance charge claimed was disapproved in Ext.A3 document as the name of the patient was not mentioned in the bill. The denial of ambulance charge cannot be treated as proper action taken by the opposite party in disbursing the claim application of the complainant. During the period of Covid-19 pandemic, it was impossible to collect proper bills for every transaction. As per covid-19 protocol physical contact was prohibited and distancing was mandatory. Moreover, in a situation where human life is in a critical stage, it is not possible to collect every bill properly. It is pertinent to note that a covid-19 patient was alone permitted to move in an ambulance. So the rejection of claim of Rs. 2,650/- to the complainant is absolutely baseless, in proper without applying prudent mind. It is also true that the complainant had spent huge amount for saving his life. The Commission find that the complainant was not responsible for the alleged excessive payment of bills to the hospital. Moreover the denial of amount allegedly spent for bystanders is also illegal. The opposite party has failed to reveal details of bystanders used by the complainant for his treatment. The treatment of covid patient was done in accordance with the directions of doctors. Moreover, there were no given formula prescribed for covid-19 pandemic treatment in Ext. B1 document. So the Commission cannot find that the amount claimed by the complainant is against the terms of the policy. The complainant had averred that his claim was improperly disbursed by the opposite party by alleging excessive amount claimed than the government guidelines for covid-19 treatment. It is also stated by the opposite party that approval of the claim was made on the basis of guidelines issued by the Government of Kerala and in accordance with the terms of the policy. It is contended by the complainant that he had directly went to the private hospital and undergone advanced treatment as he was seriously affected by covid-19 pandemic. It is also contended that his vital organs are damaged due to covid-19. These aspects were not denied by the opposite party. Also, the opposite party did not challenge the genuineness of bills produced by the complainant .
9. In the evaluation of evidence, it can be seen that a valid policy coverage was existed during the time of treatment. But the opposite party did not disburse the claim amount on the ground that Government of Kerala had issued guidelines by fixing rates for Covid-19 treatment. The Commission find that the contention of the opposite party cannot be considered for the proper adjudication of the matter. The fact availed before the Commission is that the complainant had undergone treatment for severe stage of Covid-19 disease and spent a long time in hospital. The details availed from Ext. B3 to Ext.B5 documents shows that the complainant had struggled to overcome from the clutches of covid-19 disease. As we know covid -19 pandemic situations had created panic in every realm of life. Due to acceleration of corona virus a grave situation prevailed in the society including medical treatment area. There was no given protocol or method of treatment availed for the treatment of covid-19 pandemic. So in order to provide treatment for Covid-19 affected people, the Government had brought measures and curbs on the rates of Covid-19 treatment. It has come out in evidence that the complainant had claimed a total of Rs. 1,90,193/-(Rupees One lakh ninety thousand one hundred and ninety three only) as per Ext. A2 document. But the opposite party approved only Rs. 1,07,022/-(Rupees One lakh seven thousand and twenty two only). This fact was not denied by the complainant in his affidavit filed in lieu of evidence. Conversely in the complaint, the complainant has made a claim of Rs. 92,562/-(Rupees Ninety two thousand five hundred and sixty two only) from the opposite party as the balance amount incurred as expenses for the treatment in Almas Hospital, Kottakkal. The Commission is relying on Ext. A2 document produced by the complainant himself. So it can be find that the opposite party is liable to pay Rs. 83,177/-(Rupees Eighty three thousand one hundred and seventy seven only) to the complainant as the balance amount of expenses incurred for the treatment of the complainant privileged under Ext .A1 document. So the Commission finds that the act of the opposite party in disbursing partial payment of the claims are amount to deficiency in service and hence complaint is allowed in the following manner:-
- The opposite party is directed to pay the balance amount of Rs. 83,173/- (Rupees Eighty three thousand one hundred and seventy three only) as the claim made in CIR/2022/181312/2609223 to the complainant with 9% interest from 15/07/2021 till the date of this order.
- The opposite party is directed to pay Rs. 50,000/- (Rupees Fifty thousand only) as compensation to the complainant for the sufferings of mental agony and hardship due to the act of deficiency in service.
- The opposite party is also directed to pay Rs. 10,000/-(Rupees Ten thousand only ) to the complainant as the cost of the proceedings.
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 order till its realisation.
Dated this 19th day of June, 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 A4
Ext. A1 : Document is the insurance policy schedule issued by the opposite party to
the complainant.
Ext. A2 : Document is the Bill Assessment Sheet –Member Payment dated
15/07/2021 issued by the opposite party to the complainant in CIR/2022/
181312/ 2609223.
Ext. A3 : Document is the Bill Assessment Sheet –Member Payment issued by the
opposite party to the complainant in CIR/2022/181312/2779053.
Ext. A4 : Document is the copy of claim form along with treatment records
submitted before the opposite party by the complainant.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext.B1 to B5
Ext. B1 : Document is the copy of policy condition issued to the complainant .
Ext. B2 : Document is the copy of discharge summary issued from Sacred Heart
Hospital.
Ext. B3 : Document is the copy of bills issued from Sacred heart Hospital.
Ext. B4 : Document is the copy of discharge summary issued from Almas hospital. Ext. B5 : Document is the copy of bills issued from Almas hospital.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
