The complainant has filed this case against the OP’s under section 11 &12 of the Consumer Protection Act 1986 and praying the following order /reliefs :-

1. Direction against the OP’s to pay a sum of Rs. 88,591/- (Eighty eight thousand five hundred and ninety one rupees) only to the complainant as reimbursement amount.
2. Direction against the OP’s to pay a sum of Rs. 2,00,000/- (Two lakhs) only to the complainant as compensation for financial loss, mental agony
3. Direction against the OP’s to pay a sum of Rs.10,000/- (Ten thousand) only to the complainant towards cost of the legal proceedings.
4. Any other order/orders which the complainant is legally entitled.

Brief facts of the complaint:

1. The OP no. 1 is a bank and the OP no. 2 is an insurance Company.
2. That the OP no. 1 offers health insurance under the tie up with OP no. 2 and the complainant purchased a group health insurance of Op no. 2 from the OP no. 1 at a premium of Rs. 1,000/- on 16.08.2018 for a sum insured of Rs. 1,00,000/- and  the OP’s issued a certificate of insurance to the complainant being in policy no. 00213000201700 which was valid from 14.03.2018 to 13.03.2019.
3. That, on 13.04.2018 the complainant was admitted to Basu’s Clinic Health Care Pvt. Ltd. with certain health complication and admitted there till 18.04.2018 and incurred a medical expense of Rs. 88,591/-.
4. That, the complainant intimate the fact to the OP no. 1 who instructed to submit original discharge summary and reports of the said treatment for the purpose of reimbursement of her claim amount of Rs. 88,591/- under the said policy.
5. That, the complainant submitted the original discharge summary along with medical reports/ documents in original in the office of the OP no. 1 for disbursement of her medical expenses.
6. That, the Op no. 1 did not provide any acknowledgement of receipt to the complainant and the claim was numbered as 341177 by the OP’s.
7. That, on 21.11.2018 the OP no. 1 intimate the complainant that the OP no. 2 vide letter dated 21.11.2018 had denied her claim as per terms and conditions of the policy for the reasons that the treatment was taken during the first 30 days of commencement of the policy.
8. That, on 16.02.2019 the complainant sent letter to the OP no. 1 requesting for settlement of the claim as she was hospitalized after the expiry of 30 days from the date of commencement of the policy.
9. That, on 23.09.2019 the OP’s asked the complainant to submit some documents and as per direction of the OP’s the complainant submitted required documents in the office of the OP No. 1 and thereafter, on 03.10.2019 the complainant requested the OP’s for reimbursement of the claim amount and the complainant also sent another letter to the OP no.1 by registered post vide postal receipt No. RW975131106IN dated 04.10.2019.
10. That, the OP’s denied / rejected the claim of the complainant due to non-availability of some documents and the said rejection was intimated to the complainant on 06.11.2019.
11. That, the OP No 1 and OP No 2 without having any valid grounds rejected the claim of the complainant though they are liable to pay the claim amount to the complainant.
12. That, the cause of action of this case arose on 13.04.2018 when the complainant was admitted to Basu’s Clinic Health Care Pvt. Ltd. and on 18.04.2018 when she was discharged therefrom and on 21.11.2018 when the claim of the complainant was rejected and also on 16.02.2019 when the complainant sent letter to the OP no.1 and on 23.09.2019 when the OP’s sent letter dated 23.09.2019 to the complainant, and on 03.10.2019 when the OP no.1 received the letter dated 03.10.2019 of the complainant requesting for reimbursement of the claim and the same is continuing.

Notice was issued from this commission. On receipt of notice the OP no.2 appeared through Vokalatnama, filed written version, denied all material allegation of the complainant. By filing written version OP No.2 has stated that, the instant case of the complainant has no cause of action to file the same and the complainant is not entitled to get any relief as prayed for. OP No.2 has also stated that, despite receiving letter from the OP’s the complainant did not submit the required medical documents and for want of required documents they have rejected the claim application of the complainant. The OP No.2 has also claims that, prior to completion of one month from the date of purchasing the policy the complainant was admitted in the nursing home and that is why as per policy condition the claim of the complainant was rejected. The OP No.2 by filing the written version praying for dismissal of this case.

OP No.1 despite receiving notice did not turned up to contest the case and that is why the instant case is proceeding ex-parte against the OP No.1.

Having hard the Ld. Advocate of both the parties and on perusal of documents filed by them the following points are taken to be considered by this commission.

POINTS FOR CONSIDERATION

1. Whether the complainant is a consumer as per the provision of C.P. Act. ?
2. Whether the case is maintainable in its present form and prayer under the provision of the C.P. Act. ?
3. Whether there is any cause of action to file this case by the complainant?
4. Whether there was deficiency in service on the part of the OP as alleged by the complainant?
5. Is the complainant has able to prove this case and entitled to get any relief as prayed for?

DECISION WITH REASONS 

All the points are taken up together for discussion to avoid unnecessary repetition and for the sake of convenience and brevity of this case.

The parties are given opportunities to prove their case. The complainant in order to prove her case adduced evidence by filing written deposition in chief in the form of an affidavit. She also filed several documents in support of her case. In written deposition the complainant on oath has specifically corroborate her case and has specifically stated on which day she purchased the policy and she also stated on which day she was admitted in the nursing home, on which day she was discharged from the said nursing home. She also stated on oath about the amount of expenditure which she incurred due to her medical treatment and she further explained about the date of giving intimation to the OP’s for disbursement of  the claim  amount.

At the time of argument Ld. Advocate of the complainant has stated that, the complainant has been able to prove her case through her evidence as well as through the documents before this commission. He also argued that, the complainant has filed the insurance policy (Annexure- A) which was issued by the OP No.2 and he also filed the discharge summary (Annexure-B) where from it is proved that, the complainant was admitted in the nursing home on 13.04.2018 and discharged therefrom  on 18.04.2018. It is also argument of the Ld. Advocate of the complainant that the OP No. 2 nowhere in the written version disputed the fact of medical expense of the complainant of Rs. 88,591 and the clause 5M(3b) of the policy terms and conditions is not explained to the complainant by the insurer and the denial of the claim of the complainant is unfair, unjustified and the same amount to unfair trade practice of the OP’s.

Ld. Advocate of the complainant referred some decisions in support of his case which are reported in 2008(69) AIC 650(P&H)/2022 live law (SC) 937/AIR 1986 SC 1571.

At the time of argument Ld. Advocate of the OP’s No.2 argued that, the complainant has failed to prove the case against the OP’s and the instant case is premature one and she praying for dismissal of this case. Ld. Advocate of the OP No.2 submits that OP No.2 was very much ready to settle the claim of the complainant if the complainant used to submit the required documents as requested to submit but the complainant did not produce those documents. She further argued that, the OP no. 2 is unable to assess, scrutinize and process the claim of the complainant as the complainant had not furnish the complete original documents and treatment papers concerning her treatment to the OP no. 2 and that is why the claim of the complainant was rightly rejected as per the terms of the policy conditions.

Having heard the Ld. Advocate of the complainant and OP No.2 and on perusal of the complaint, written version, evidence of the parties including the documents annexed it is not disputed that the complainant is a policy holder. It is also not the case of the OP No.2 that, Health Insurance Policy was not issued by the OP No.1 and 2 to the complainant being in policy no. 00213000201700 valid from 14.03.2018 to 13.03.2019.

It is admitted by the OP No.2 that the complainant was admitted in the Basu’s Clinic Health Care Pvt. Ltd on 13.04.2018 and discharged on 18.04.2018.

It is further admitted fact that, within the effecting period of health insurance policy the complainant was admitted in the nursing home and incurred medical expense of Rs.88,591/-.

It is not denied by the OP’s that the complainant submitted annexure-B (Discharge summary) to the OP’s for settlement of the insurance claim.

From careful scrutiny of entire record it reveals that, the complainant has been able to prove the fact that, she has sufficient cause to file this case. The cause of action had arisen to the complainant to raise claim of medical expenses incurred for medical treatment as she was treated in the nursing home during  the subsistence of the health insurance policy and denial of the claim by the OP’s would negate the social and beneficial purpose of the said scheme.

It is needless to mention here that, the OP No.1 intimated the complainant on 21.11.2018 by stating that the OP No.2 denied the claim of the complainant being in no 341177 on the grounds that the treatment of the complainant was taken during the first 30 days of the commencement of the insurance policy. But the said claim of the OP’s are not at all correct. Because the complainant purchased the health insurance policy which was valid from 14.03.2018 to 13.03.2019 and it is proved from the Annexure-A and B that the complainant was treated medically after 30 days from the date of commencement of the insurance policy. Accordingly we are of the view that, the grounds taken by the OP’s are not correct/true or convincing.

The OP’s vide letter dated 23.09.2019 requested the complainant for submitting first prescription for rheumatic arthritics and hypertension, previous treatment records relating to cerebral infract, indoor case papers with admission notes etc. Receiving that letter of the OP’s the complainant submitted all her documents to the OP’s for settlement of her claim application. But by communication dated 06.11.2019 the OP’s intimate the complainant that they have rejected the claim for want of documents though it was held by the Hon’ble Supreme Court in Gurmel Singh versus Branch Manager, National Insurance Co. Ltd. In 2022 Live Law (SC) 506 that, in many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents which the insured is not in a position to produce due to circumstances beyond its control. The Hon’ble Supreme Court also observed that, once there is a valid insurance on payment of premium the insurance company ought not to have become too technical and ought not to have refused to settle the claim on flimsy grounds.

Considering the evidence of the complainant and her documents including the written version of the OP no. 2 we are of the view that, the complainant has been able to prove her case against both the OP’s and she is entitled to get relief as the OP’s had/have duties /liabilities towards the insured which they did not comply or did not obey their duties and the same is nothing but the deficiency in service as well as restrictive trade practice on the part of the OP’s.

Hence, it is therefore,

O R D E R E D

That, the instant Consumer Case being in No. 64/2019 is hereby allowed on ex-parte against the OP no. 1 and allowed on contest  against the OP no. 2 but in part. The OP’s are jointly and severally liable to pay a sum of Rs. 88.591/- (Eighty eight thousand five hundred and ninety one rupees) only to the complainant towards medical expenses incurred by the complainant and direction is given to the OP no. 1 and OP no. 2 in this regard to pay the same.

The OP’s are also directed to pay a sum of Rs. 50,000/- (Fifty thousand rupees) only to the complainant for compensation for deficiency in service as well as mental agony caused to the complainant by the OP’s.

The OP’s are also directed to pay a sum of Rs. 10,000/- (Ten thousand rupees) only to the complainant as cost of legal proceedings and the OP’s are also directed to pay a sum of Rs. 10,000/- (Ten thousand rupees) only to the Consumer Legal Aid account of this commission.

The OP’s are directed to pay the above amount within a period of 45 days from this day failing which they will have to pay interest @ 9 % per annum to the complainant till making payment of the entire amount.

Let a copy of this final order/judgment be given to the parties free of cost.