BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE

Dated this the 2^nd June 2017

PRESENT

   SRI VISHWESHWARA BHAT D     : HON’BLE PRESIDENT

SMT.LAVANYA M. RAI                 : HON’BLE MEMBER

ORDERS IN

C.C.No.184/2015

(Admitted on 26.5.2015)

Smt. K. Sanjeevi,

W/o Chandrahasa,

Aged about 74 years,

R/at. AshwiniNilaya,

Near Malaraya Daivastana Dwara,

Urwa Chilimbi,

Mangalure 575006.

                                                        ….. COMPLAINANT

(Advocate for the Complainant bySri DK)

VERSUS

1. United India Insurance Company Ltd,

          Represented by their Divisional Manager,

          Divisional office, Post box No.705,

         1^st floor Rama Bhavan Complex

          Kodial Bail, Mangalore 575003.

2. Vidal Health TPA Pvt. Ltd,

           Represented their Manager,

           City plaza, 2^nd floor,

           No.201 and 203, KRR Road,

           Shedigudde, Near PVS circle,

           Mangalore 575003.

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

(Advocate for the Opposite Party No.1: Sri AKK)

(Opposite Party No.2: Ex parte)

ORDER DELIVERED BY HON’BLE PRESIDENT

SRI VISHWESHWARA BHAT D:

     The above complaint filed under Section 12 of the Consumer Protection Act by the complainant against opposite parties alleging deficiency in service claiming certain reliefs. 

The brief facts of the case are as under:

The complainantclaims since 10 years she renewing health insurance policy obtained from Opposite Party No.1 on 5.8.2014.  she was admitted to Mangalore Nursing Home, Bendore, Mangalore diagnosed of suspected cancer in right breast at was discharged of surgery on 12.8.2014 and when which was the Opposite Party No.1 had issued the policy for the period from 25.2.2014 to 24.2.2015 was intimated about the hospital admission she was informed to make a payment at the hospital at the time of discharge she paid Rs.41,800/ the amount of the hospital and spent of Rs.4,510/ towards clinical laboratory tests. On discharge when complainants is family approached and contacted Opposite Party No.1 it was informed the amount is required to pay the entire amount of the hospital bill at the hospital before discharge and Opposite Party No.2’s 3^rd party administrator will reimburse the same to her.  However when complainant submitted bills to Opposite Party No.2 an amount of Rs.14,786/ the loan of the total bills she was allowed by Opposite Party No.2.  Remaining a balance of Rs.31,524/- and total claim less than Rs.50,000/.  Even though legal notice served on Opposite Party No.1 and 2 Opposite Party No.1 gave enable document and unreasonable to reply hence seeks reliefs claimed by the complainant.

2.     Opposite party No.1 in the versionwhile admitting the insured coverage under policy issued to the complainant denies the hospital expenses Rs.41,800/ and clinical test charges Rs.4,510/. Liable to pay the balance amount of Rs.31,524/ denied.  Opposite Party No.2 the TPA investigated the claim and made the expenses incurred in respect of Room rent, boarding and Nursing expenses as provided by the hospital/nursing home shall not exceed 1% of the sum insured per day or the actual amount whichever is less and this also included nursing care RMO charges, IV fluids/Blood transfusion/ injection administration charges and similar expenses. The amount payable under 1.2 C and D of the policy that shall be at the rate applicable to the entitled room category and in case the insured opts for a room with rent higher hand the entitled category as in 1.2 (A) the charges payable under 1.2 C and D shall be limited to the charges applicable to the entitled category.  Hence TPA settled the claim of the complainant for Rs.14,786/, hence seeks dismissal.

3.     In support of the above complaint Smt.K. Sanjeevi, filed affidavit evidence as CW1 and answered to the interrogatories served on her andproduced documents got marked at Ex.C1 to C9 as detailed in the annexure here below.   On behalf of the opposite partiesMr.Pundalik M Nayak (RW1) Divisional in charge, also filed affidavit evidence and answered to the interrogatories served on him and produce documents got marked at Ex.R1 as detailed in the annexure here below.

4.     In view of the above said facts, the points for consideration in the case are:

1. Whether the Complainant is a consumer and the dispute between the parties?
2. If so, whether the Complainant is entitled for any of the reliefs claimed?
3. What order?

     The learned counsels for both sides filed notes of arguments.  We have considered entire case filed on record including evidence tendered by parties.   Our findings on the points are as under follows:

              Point No. (i) : Affirmative

               Point No. (ii) : Negative

              Point No.(iii): As per the final order.

REASONS

5.     POINTS No. (i):The policy issued by Opposite Party No.1 to complainant and thereby relationship ofconsumer and service provider between the parties un disputed.  The claim for reimbursement of entire of hospital expenses is disputed by Opposite Party on various counts, hence there is live dispute between the parties as contemplated under section 2 (1) (e) of C.P. Act. Hence we answer point no. 1 in the affirmative.

6.    POINTS No. (ii):The amounts claimed by complainant as hospital expenses and investigations charges is not disputed by Opposite Parties.  The only ground under which Opposite Party to substantiate the claim is under the policy of Ex.C1 restrictions clause 1.2 reads thus:

In the event of any claims(s) becoming admissible under this scheme, the company will pay through TPA to the hospital nursing home or the insured person the amount of such expense as would fall under different heads mentioned below and as are reasonably and necessarily incurred thereof by or on behalf of such insured person, but not exceeding sum insured in aggregate mentioned in the schedule hereto.

1. Room, Boarding and nursing expenses as provided by the Hospital/Nursing Home upto 1% of sum insured per day.  This also includes nursing care, RMO charges, IV Fluids/Blood Transfusion/ injection administration charges and similar expenses.
2. If admitted in IC Unit, the company will pay upto 2% of sum insured per day or actual amount whichever less.
3. Surgeon, Anaesthetist, medical practitioner, consultants, specialists fees.
4. Anaesthetist, blood, oxygen, operation theatre charges, surgical appliances, medicines and drugs, dialys chemotherapy, radiotherapy, cost of Artificial limbs, cost of prosthetic devices implanted during surgery procedure like  pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory diagnostic tests, Xray and such similar expenses that are medically necessary. 
5. All hospitalisation expenses (excluding cost of organ, if any) incurred for donor in respect of organ transplant to the insured.

Reference was also made for complainant to clause 1.2.1 Expenses in respect of the following specified illnesses will be restricted as reads thus:

7.    It was argued for complainant that at least 50% of the sum insured the expenses incurred shall be paid i.e. Rs.35,000/ should have been paid by Opposite Party.  However as we can make from Ex.C1 the coverage mentioned in clause 1.2 and 1.2.1 is not exclusive of one over the other.  Hence in our view the complainant cannot seek to take under clause 1.2.1 of the admissibility as per clause 1.2.  In any case the 70% or of the sum insured or actual expensesmentioned that 1.2.1 he is only in respect of major surgeries and in respect ofHernia Operation i.e. 1.2.1 (A) mentioned above it is only actual expenses or Rs.25% whichever is lessof sum ensured.  Hence the claim of complainant onthis count, in the circumstances we are of the opinion that when complainant has not demonstratedviolation of terms of Ex.C1 the policy by Opposite Parties.  Hence complainant failed to prove deficiency in service on the part of Opposite Parties, hence we answer pointsNo.2 in the negative.

POINTS No. (iii):Wherefore the following order

ORDER

The complaint is dismissed.

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

     (Page No.1 to 6 directly typed by steno on computer system to the dictation of President revised and pronounced in the open court on this the2^nd June 2017)

               MEMBER                                        PRESIDENT

      (LAVANYA M. RAI)                 (VISHWESHWARA BHAT D)

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

              Mangalore                                         Mangalore

ANNEXURE

Witnesses examined on behalf of the Complainants:

CW1  Smt.K. Sanjeevi

Documents marked on behalf of the Complainants:

Ex.C1:Individual Health Insurance policy

Ex.C2: Discharge summary

Ex.C3: Hospital bills and receipts dated 12.8.2014

Ex.C4: Copy of Bank pass book.

Ex.C5: Legal notice dated 29.11.2014.

Ex.C6: Reply to the legal notice 24.12.2014.

Ex.C7: Acknowledgement cards

Ex.C8: Postal receipt 2 Nos.

Ex.C9: Mediclaim Computation sheet.

Witnesses examined on behalf of the Opposite Parties:

RW1  Mr.Pundalik M Nayak (RW1) Divisional in charge

Documents marked on behalf of the Opposite Parties:

Ex.R1: Individual Health Insurance policy bearing  No.070800/48/13/97/00002851 to the complainant.

Dated: 02.06.2017                    PRESIDENT