BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 28th October 2016
PRESENT
SMT. C.V. SHOBHA : HONBLE PRESIDENT
SMT.LAVANYA M. RAI : HONBLE MEMBER
COMPLAINT NO.157/2013
(Admitted on 29.05.2013)
Mrs. Shashikala,
W/o Late Kishor,
Aged about 40 years,
R/at C.B. Compound,
Bhavanthi Street, Mangalore.
……… Complainant
(Advocate for Complainant by Sri. SK)
VERSUS
- Dedicated Health Care Services,
TPA (India) private Ltd,
25-8-497, 1 (2), 1st floor,
Arjun Anjali Compound,
Opp to Shiva Restaurant,
Gorigudda Velencia,
Mangalore 575002.
- National Insurance Company Ltd,
Mangalore Division Office II Floor,
Rasik Chamber,
Opp. Central Market Mangalore.
- Indira Hospital, Falnir Road,
Mangalore, Represented by its Medical,
Superintendent.
…. Opposite Parties
(Opposite Parties No.1 and 3: Ex parte)
(Advocate for the Opposite Parties No.2. Sri: UNK)
ORDER DELIVERED BY HON’BLE PRESIDENT
SMT. C.V. SHOBHA
- 1. This complaint is filed under section 12 of the Consumer Protection Act alleging deficiency in service as against the opposite parties claiming certain reliefs.
2. The Opposite Parties be directed to pay to the complainant a sum of Rs. 50,000/ being the damages which is illegally repudiated by the Opposite Parties to the complainant, with interest at the rate of 18% from the date of complaint till the date of payment, mental agony and such other further suitable relief’s to be granted as the Forum deems fit under the circumstances of the case.
II. The brief facts of the case are as under:
The complainant is the Mediclaime insurance policy holder with Opposite Party No.1 Company as per Policy No. 604300/48/12/8500000077. The complainant had suffered from Left Legg Post Traumatic Effusion Anemia in this regard she has taken treatment as inpatient from 25.08.2012 to 28.08.2012 at Indira Hospital, Falnir Road, Mangalore.
The complainant submits that immediately after discharge from the Indira Hospital, she filed a claim form before the Opposite Party No.1 along with the Original Discharge Summary and Bill issued by the Indira Hospital for sum of Rs. 6,528/- to the aforesaid treatment under her aforesaid policy. In spite of the claim form given by the complainant, the Opposite Party No.1 issued reply and repudiated the claim of the complainant under the ground that hospital authority has not justified the correct treatment given to the complainant during her inpatient treatment in the Opposite Party No.3 hospital. The Opposite Party No.3 given treatment could be administered on OPD basis, on the above ground the claim of the complainant inadmissible as per clause 5.8 of the policy term. Also there is discrepancy between the documents submitted by Opposite Party No.3 before the Opposite Party No.1.
The complainant got valid insurance policy from 18.04.2012 to 17.04.2013, it is in during the time of treatment taken by her in the aforesaid Opposite Party No.3 hospital. the complainant issued a letter to the Opposite Party No.1 grant her claim amount for her aforesaid treatment taken under the Opposite Party No.3. The Opposite Party No.1 has not justified the other reason to repudiate the claim except the aforesaid reason set out in the notice. The copy of the discharge summary and medical bill clearly born out the nature of treatment and duration of treatment administered by the Opposite Party No.3 to the complainant as inpatient. Complainant has been produced aforesaid documents along with the complaint, it may be read as part of the complaint for appreciating the contention of the complainant. The complainant submits that the reason given by the Opposite Party No.1 and 2 for rejection of her claim is without any valid grounds and it clearly amounts to deficiency of service in pursuance of a contract between the complaint. Hence this complaint.
III. Version Notice served to the opposite party by RPAD filed version. Further submitted that there are several types of insurance policies. The risk covered also varies depending upon the requirements of the customers. Though the complainant is the mediclaim insurance policy holder under Opposite Party No.2 Company as per policy No. 604300/48/12/8500000077, it is very clearly shown in the terms and conditions that there are some exclusion clauses. It is denied that the complainant had suffered the alleged Left Legg Post Traumatic Effusion Anemia or needed treatment as inpatient from 25.08.2012 to 28.08.2012 at Opposite Party No.3.
On scrutiny of said documents submitted, the claim form given by the complainant along with the original discharge summary and bill issued by the Indira Hospital Opposite Party No.3 for a sum of Rs. 6,528/ was rejected by giving reply that, hospital authority Opposite Party No.3 has not justified about the correct treatment given to the complainant when she was treated as inpatient in the Opposite Party No.3 hospital, the treatment given by the Opposite Party No.3 could be administered on OPD basis and there is discrepancy between the documents submitted by the Opposite Party No. 3 before the Opposite Party No.1.
Further submitted that after scrutiny of the records, and applying the Policy conditions, the claim was repudiated. After reviewing the file of the complainant by M/s Dedicated Healthcare Service TPA (India) Private Limited and on the basis of representation of the complainant and later is not payable as there is discrepancy in the documents submitted to Opposite Party No. 1 during cashless authorization and reimbursement line of treatment is different. The claim was initially rejected as Hospitalization not justified and the given treatment could be administered on OPD basis i.e. only inj Diclogen Tab, Rabium Ta, Zymoflam D Tab, Triple A Cal OS and Cap A to Z. But the documents submitted for reconsideration shows Inj. Taximax, Voveran and Glycerine Mag Sulphate dressing as treatment given in discharge summary. Hence, the claim falls under condition No.5.8 of Universal Health Insurance policy and hence the complainant is not entitled for any claim under the aforesaid policy. In support of the complainant One Mrs. Shashikala, (CW1) complainant No.1 filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on him and produced the document got marked as Ex C1 to C9. Opposite Party No.2 filed affidavit of One. K.Padmaprakash Rao, (RW1) and also interrogatories served by him no documents produced by Opposite Party No.2. Opposite Party No.1 and 3 are Ex parte.
IV. In view of the above said facts, the points now that arise for our consideration in this case are as under:
- Whether the complainant proves that there is a deficiency of service on the part of Opposite Parties as per the complaint?
- If so, for what quantum and from whom the complainant in entitled?
- What order?
We have considered the notes/oral arguments submitted by the learned counsel and also considered the materials that was placed before this Forum and answer the points are as follows:.
Point No. (i): As per Affirmative
Point No. (ii): As per Affirmative
Point No. (iii): As per the final order.
REASONS
V. POINTS No. (i) and (ii): The complainant in the above case made the dispute for claiming the amount from the Opposite Party No.1 and 2 on the basis of the said mediclaim insurance policy issued by Opposite Party No.1 along with its agent Opposite Party No.2 vide policy No. 604300/48/12/8500000077, valid from 18.04.2012 to 17.04.2013. Further, the complainant took treatment as M/s Indira Hospital, Falnir Road, Mangalore in Indoor Patient from 25.08.2012 to 28.08.2012 in the hospital with Opposite Party No.3 M/s Indira Hospital. During the Hospitalization, she was treated for her ailment of Left Legg Post Traumatic Effusion Anemia and incurred a total expenses of Rs. 6,528/ towards hospital charges, lab charges, X-ray, room rent, medicine and doctor consultation charges and paid the same at the time of discharge from the hospital. As such, she made a claim after being discharged from M/s Indira Hospital, Falnir Road, Mangalore along with the necessary documents and requested for the refund of the same from the Opposite Party No.1 and 2. Thereafter, Opposite Party No. 2, refused to make the good of her claim. Instead, the Opposite Party No.1 took a plea that the company shall not be liable to make any payment under this policy in respect of any claim if such claim be, in any manner, fraudulent or supported by any fraudulent means or device whether by the insured person or by any other person acting on this behalf. Both the Opposite Party No.1 and 2 issued the said repudiation letters as on 05.10.2012 and 26.10.2012 respectively. Hence, this complaint was raised by the complainant before us against the Opposite Parties for the relief as sought for.
The plea taken by Opposite Party No.1 and 2 in the said repudiation letter based on the terms and conditions (vide No. 5.8) was not disclosed at the time of issuing the policy schedule. In such a situation, is crystal clear that, only with a view to escape liability, the Opposite Party No. 1 and 2 have taken the said false plea on the basis of the said alleged terms and conditions as contemplated in the so called document that is, Universal Health Insurance Policy Scheme of the Opposite Party No.2. Also, nothing regarding the said terms and conditions is mentioned in the said policy schedule issued by Opposite Party No.2 to the complainant. Further, it is also an admitted fact that in the date of commencement of the mediclaim policy that on 18.04.2012, the net premium of Rs.300/- was collected and the said policy also clearly goes to show that stating sum insured for each family is Rs.30,000/. Even in such a situation, neither of the Opposite Party No.1 and 2 make the good of the claim of the complainant to a tune of Rs. 6,528/, actually it was paid by her to the said hospital as per the discharge till dated 28.08.2012. Those documents of the hospitals are accompanied with many other documents pertaining to her treatment such as, Exhibit C7 containing admission record is consent form, including case sheet etc, maintained by the Opposite Party No.3 hospital during the course of her treatment given as an indoor patient. Both the Opposite Party No.1 and 2 to make the payment/ refund of the said total sum of Rs. 6,528/ to the complainant on the basis of her claim form Ex. C2. All of the above reasons together with pleadings, oral and documentary evidence, notes of arguments, we come to a conclusion that the complainant was admitted in Opposite Party No.3 hospital and took treatment as an indoor patient for her ailment of left leg post tracematic effusion anemia, from 25.08.2012 to 28.08.2012. On the contrary the Opposite Party No.1 and 2 taken a contention that as per Ex C6 claim is not payable as there is discrepancy in the document submitted to them during cash less authorization and reimbursement- line of treatment is different. As such, the Opposite Party not adduced any evidence or not produced any documents to prove the case. On treatment could be admitted on OPD basis. Hence there is a deficiency of service on the part of Opposite Party No.1 and 2. It also amounts to unfair trade practice. Hence, we hold the above point No. 1 and 2 in the affirmative. Further, the Opposite Party No.1 and 2 jointly and severally are liable to pay/ refund the said sum of Rs. 6,528/ together with interest at the rate of 10% p.a, computing from 28.08.2012 till realization to the complainant. Further, a compensation of a sum of Rs. 3,000/ is to be paid by Opposite Party No.1 and 2 to the complainant for having caused harassment and mental agony. The Opposite Party No.1 and 2 are also liable to pay another sum of Rs. 3,000/ towards cost and litigation charges incurred by the complainant. Complaint against Opposite Party No.3 is dismissed.
POINTS No. iii: In the result, as per the Order below:
ORDER
The complaint is allowed in part. The Opposite Parties No.1 and 2 jointly and severally are held liable and responsible to pay for a sum of Rs. 6,528/ (Rupees six thousand five hundred twenty eight only) with accrued interest at the rate 10% p.a from the date of 28.08.2012 till realization. Further Opposite Parties are also liable to pay for a sum of Rs. 3,000/(Rupees three thousand only) towards compensation and another sum of Rs.3,000/(Rupees three thousand only) towards cost and litigation expenses incurred by the complainant. Payment shall be made within 30 days from the date of receipt of this order.
Copy of this order as per statutory requirements, be forwarded to the parties and therefore the file shall be consigned to record room.
(1 to 8 pages dictated to the Stenographer typed by her, revised and pronounced in the open court on this the 28th day of October 2016)
MEMBER PRESIDENT
(SMT. LAVANYA M.RAI) (SMT. C.V.SHOBHA)
D.K. District Consumer Forum D.K. District Consumer Forum
Mangalore. Mangalore.
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1: Mrs. Shashikala,
Documents marked on behalf of the Complainant:
Ex.C1: Dated: 2012. 2013 Mediclaim policy issued by the Opposite Party No.2
Ex.C2: Dated: 22.11.2012 Claim Form given by the complainant to Opposite Party No.1.
Ex.C3: Dated: 21.02.2012 Letter given by the complainant to Opposite Party No.1
Ex.C4: Dated: 28.08.2012 Discharge summary issued by the Opposite Party No.3
Ex.C5: Dated: 28.08.2012 discharge bill receipt.
Ex.C6: Repudiation of claim letter issued by the Opposite Party No.1 and 3 (3 in Number)
Ex.C7: Admission record and consent form.
Witnesses examined on behalf of the Opposite Parties:
RW1: K.Padmapraksh Rao
Documents produced on behalf of the Opposite Parties:
Nil
Dated: 28.10.2016. PRESIDENT
