BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE    

Dated this the 7^th March 2017

PRESENT

SRI. VISHWESHWARA BHAT D         : HON’BLE PRESIDENT

SRI. T.C. RAJASHEKAR                       : HON’BLE MEMBER

ORDER IN

C.C.No.439/2014

(Admitted on 22.11.2014)

Mr. Shashiraj. A,

S/o Late John Ambat,

Aged 57 years,

R/at D.No.4H, 109.D, 6^th Cross,

Girinagar, landlinks, Derebail,

Konchady, Mangalore 575008.

                                                                ….. COMPLAINANT

(Advocate for the Complainant: Sri DSA)

VERSUS

1. The Divisional manager,

United India Insurance Company Ltd,

Divisionional Office, Post Box No.705,

1^st floor, Rama Bhavan Complex,

Kodialbail, Mangalore 575003.

2. The Chief Executive Officer,

TTK Healthcare Services P. Ltd,

11^th Floor Brigade Towers,

139, Brigade Road,

Bangalore 560025.

                                                     ….........OPPOSITE PARTIES

 (Advocate for the Opposite Party: Sri MVSB)

ORDER DELIVERED BY HON’BLE MEMBER

T.C. RAJASHEKAR:

I.   1. The above complaint filed under Section 12 of the Consumer Protection Act 1986 alleging deficiency in service against the Opposite Party claiming, to pay a sum of Rs.49,325/ remaining balance insurance, to pay a sum of Rs.5,796.61  post hospitalization medical expenses, to pay a sum of Rs.150/ per day for 60 days the expenses incurred for nutrition,  to pay a sum of Rs.10,000/  attendant fees for 60 days during the post hospitalization period, to pay interest at the rate of 14% p.a. till the date of actual payment  and such other reliefs.

2.       In support of the above complaint the complainant Mr. Shashiraj. A, filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked Ex.C1 to C9 as detailed in the annexure here below.  On behalf of the opposite party Amar Kumar Sinha, Sr Dn Manager, (RW1) of opposite party also filed affidavit evidence and answered the interrogatories served on him.

      The brief facts of the case are as under:

          We have perused the complaint and the version filed by the parties.  This dispute is with regard to partial repudiation of mediclaim insurance claim by the Opposite parties. The complainant alleges that he had obtained a mediclaim family insurance policy from the opposite parties. From 24.12.2013 to 04.01.2014 his wife on complain of abdomen pain undergone uterus related problem operation. The complainant claimed the expenses of Rs. 89,325/ But the opposite parties allowed only Rs. 40,000/ and refused the balance on the ground the exclusion condition in the policy.  Complainant alleges The opposite party while issuing policy have taken signature of the complainant on the blank papers and the papers with blank column and later filled up. The condition of the policy is not revealed by the opposite party. The Opposite parties contested the case and stated that as per policy condition the maximum amount of expenses allowed for the treatment undergone is not exceeding 20 % of the sum assured (SI). In the case of the complainant it will be Rs.40,000/ on Rs.2,00,000/ sum assured. As per policy condition the allowed claim is correct and the same has been paid to the complainant. These are being the facts of dispute in resolving it we consider the following 

POINTS FOR ADJUDICATION

          We have considered the evidence of the parties and the documents produced by the complainant. The admitted facts are the family mediclaim Insurance policy issued to the complainant, hospitalization of the complainant’s wife Mrs Vijaya Shashi Raj for the complaint of abdominal pain and diagnosed as uterus related problem and operation done. It is not denied that the complainant submitted the claim for Rs.89,325/ and the opposite party paid only Rs.40,000/ as allowed claim amount. It is denied that the policy condition revealed to the complainant and as per policy condition the complainant claim can be allowed only to Rs. 40,000/- and also denied the blank forms with blank columns got signed by the opposite party from the complainant while submitting policy proposal. Admissions and the denials reconciled and considered the following points for adjudication.

1. Whether the complainant is a consumer under the consumer protection Act 1986?
2. Whether opposite party proves the settlement of claim amount proper and justifiable?

3. Whether the complainant is entitled for the relief prayed for?
4. What order?

   We have closely traversed through the documents produced and policy copy. The evidence lead by the parties considered and notes of arguments taken note of. Heard the submissions of counsels of the parties and answered the above points as under:

1. In the affirmative.
2. In the negative.
3. In the affirmative partly.
4. As per delivered order.

REASON

POINT NO 1: The complainant had produced the mediclaim insurance policy EX C 1 to C1(c) which has been issued in the name of the complainant herein. It is not denied by the Opposite parties that the complainant is the consumer. Hence obviously we answered the point No 1 in the affirmative.

POINT NO 2: It is the case of the complainant that he had obtained a mediclaim family insurance policy for Rs 2 lakhs and the complainants  wife admitted to hospital and undergone the operation and treatment related to uterus problem. In spite of insurance coverage for 2 lakhs, the complainant’s wife medical treatment bill of Rs. 89,325/ was not settled but only a partial amount of Rs.40,000/ only paid. The Opposite partys not denying these facts. But the opposite party contention is as per policy condition the maximum amount payable to the treatment of Hysterectomy is 20 % of the sum assured i.e. Rs.40,000/. And the same has been paid. Hence it is the Opposite parties burden to prove that as per policy condition the amount payable is only Rs. 40,000/ as such the point no 2 taken for consideration. In para 4 of version the Opposite parties states that, the only controversy between the complainant and this opposite party is as to whether entire bill amount of the medical expenses has to be paid as per terms of the policy or it is only certain percentage of the insured amount that is payable?   The opposite party relies on the policy condition in 1.2 in page 3 which states under sub clause A to E. The different heads of expenses payable subject to certain percentage of the sum assured and continued with a schedule captioned as expenses in respect of the following specified illness will be restricted as detailed below under which the (c) Hysterectomy is limited to maximum of 20 % of sum assured (SI) subject to maximum of Rs.50,000/ Based on these condition opposite party argues the amount of Rs.40,000/ is payable. In page 3 para 10 of the version it is clarified that if the percentage of SI goes beyond Rs. 50,000/ then only maximum Rs.50,000/ is payable. What we observe from the record and documents that nowhere the opposite party shown that the complainants wife undergone the Hysterectomy operation and treatment for it. On glance of the bill produced by the complainant it is not revealed that the complainant wife under gone Hysterectomy or opposite parties not drawn our attention to the record where it is mentioned as Hysterectomy operation. In the outset the opposite party not justified in applying the clause 1.2 of the policy relied upon.  They may argue it is an admitted fact by the complainant. We have gone through the complaint averments to see any admission to this effect.    

          In para 5 of the complaint the complainant stated that, The complainants wife Mrs. Vijajaya Shashiraj starting suffering from abdominal pain and it was diagnosed as Uterus problem. After consultation...as inpatient from 24.12.2012 till 04.01.2014. During this period of hospitalization the complainants wife had to undergo one major and one minor surgical operation.  The complainant did not say the operation is Hysterectomy but only said the diagnosed as uterus problem. The complainant also said his wife during the hospitalization under gone two surgical operation. If it is to taken as admission it is to be taken in whole. The fact of two surgical operations undergone also to be considered not only the Hysterectomy and the application of clause 1.2 in page 3 of the policy the 20% maximum cannot be applied.

2. Apart from this the complaint produced EX-C 3. In second sheet Mediclaim Computation Sheet it is mentioned in tabulation the Nature of expenses, Amount claimed, Non admissions expenses, Amount allowed and remarks. In that some of the nature of expenses shown as not admissible either fully or in part. The reason given is EXCEEDS ALIMENT CAP. We lost to understand in which part of the policy the said ALIMENT CAP is fixed to substantiate the dis allowing the expenses. The other point is when there is fixation of maximum limit of 20 % of SI which amounts to Rs.40,000/ as claimed by opposite party why this kind of tabulation and item wise Mediclaim Computation Sheet baselessly founded was necessitated.

3. There is also mention in the clause 1.2 of the policy with regard to Pre and post hospitalization expenses which is allowable either actual or maximum of 10 % of the sum assured. Obviously there will be pre and post hospitalization expenses. We also seen some of the bills of date before operation and also after the date of operation. The opposite party is silent about these expenses. By taking into all these facts into consideration we hold the opposite party not proved the amount settled as correct and as per policy condition and there is no justification in allowing only Rs. 40,000/ as claim. Hence we hold the opposite party is liable for deficiency in service and answered the point no 2 in the negative.

POINT NO 3: As per the above discussion we hold the opposite party not justified in considering the mediclaim policy amount and liable for deficiency in service. The complainant is entitled for the amount of Rs.89,325/ as treatment expenses and the opposite party already paid Rs.40,000/ and hence the complainant is entitled for an amount of Rs.49,325/ with an interest of 9 % per annum from the date of first payment in part  settled till the date of payment.  with regard to other claims of post operation expenses the majority of the bills produced by the complainant is related to date after 60 days elapsed from the date of treatment and not clear and substantiated hence not considered. Other reliefs nutrition and attended fees the complainant not established that it is payable as per policy hence deserves not to be allowed. The complainant also entitled for an amount of Rs. 10,000/ as compensation as we see negligence from the part of the opposite party in appreciating the policy and adopting the clause 1.2, and an amount of Rs. 7,000/ as litigation expenses.

POINT NO 4: In the light of above discussion and adjudication of the above points we deliver the following

ORDER

The complaint is partly allowed. The Opposite parties shall pay the complainant an amount of Rs.49,325/(Rupees Forty nine thousand three hundred twenty five only) with an interest of  9% per annum from the date 29.01.2014 (as per pass book entry first payment in part settled) till the date of payment and an amount of Rs.10,000/(Rupees Ten thousand only) as compensation and amount of Rs.7,000/ (Rupees Seven thousand only) towards litigation expenses within 30 days from the date of copy of this order received.

     Copy of this order as per statutory requirements, be forward to the parties free of costs and file shall be consigned to record room.

(Page No.1 to 9 directly typed by Member, revised and pronounced in the open court on this the 7^th   March 2017)

            MEMBER                                              PRESIDENT

        (T.C. RAJASHEKAR)                        (VISHWESHWARA BHAT D)

  D.K. District Consumer Forum                D.K. District Consumer Forum

Additional Bench, Mangalore                   Additional Bench, Mangalore

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1  Mr. Shashiraj. A,

Documents marked on behalf of the Complainant:

ExC1: Family Medicare policies (4 in No.s)

ExC2: Particulars of Medical bills.

Ex.C3: Reimbursement claim Approval Letter Dated 31.1.2014.

Ex.C4: Legal Notice Dated 6.2.2014.

Ex.C5: Reply Notice Dated 11.2.2014.

Ex.C6: Reply Notice Dated 4.3.2014.

Ex.C7: Notarized copies of medical bills and receipts.

Ex.C8: original Medical Bills and Receipts.

Ex.C9: original Pass book.

Witnesses examined on behalf of the Opposite Parties:

RW1:  Amar Kumar Sinha, Sr Dn Manager.

Documents marked on behalf of the Opposite Parties:

Nil

Dated:  07.03.2017                             MEMBER