BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 31ST MAY, 2016
PRESENT
SMT. ASHA SHETTY : PRESIDENT
SMT.LAVANYA M. RAI : MEMBER
COMPLAINT NO.378/2012
(Admitted on 15.12.2012)
Percy Noel Pais,
S/o George Pais,
Aged about 56 years,
D.No.6-20, Mother Teresa Road,
Jakribettu House, Bantwal,
Church Road, Bantwal. …….. Complainant
(Advocate for the Complainant: Sri Sharath Kumar)
VERSUS
1. Manager (Authorized Signatory)
TATA AIG General Insurance Co. Ltd.,
3rd Floor, Mangalore Gate Building,
Kankanady, Mangalore Branch,
Mangalore.
2. Manager (Authorized Signatory),
TATA AIG General Insurance Co. Ltd.,
Peninsula Corporate Park,
Mumbai – 400013.
……. Opposite Parties
(Opposite Party No.1 : Exparte)
(Advocate for the Opposite Party No.2: S.K.Ullal)
***************
ORDER DELIVERED BY HON’BLE PRESIDENT
SMT. ASHA SHETTY:
I. 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.
The brief facts of the case are as under:
The complainant stated that he has been insured with the Opposite Party under the Health Insurance Policy i.e. “Hospital Cash Health Policy” bearing No.0250042061 by paying an annual premium of Rs.4,220/-. During the said validity of the above said policy Complainant got admitted to the hospital as an inpatient from 13.10.2011 to 22.10.2011 in Govt. Community Hospital for acute neck pain which was later diagnosed as cervical C5-C6 Spondylosis. After the treatment the Complainant submitted the relevant documents to the Opposite Party Company but on 09.01.2012 the Opposite Party repudiated the claim stating that the treatment could have been taken on OPD basis and there is no need of admission. It is contended that the Opposite Party without any valid grounds repudiated the claim hence the Complainant issued a lawyer notice dated 14.05.2012 to comply the demand made therein but the Opposite Party failed to comply the demand hence, the above complaint U/s 12 of the C.P. Act seeking direction from this Fora to reimburse the medical expenses and also to compensation and cost of the proceedings.
II. 1. Version notice served to the Opposite Party by R.P.A.D. The Opposite Party No.1 did not chose to appear before this and remained absent, hence placed exparte. Opposite Party No.2 appeared through their counsel filed version denying the deficiency and stated that on receipt of the claim from the Complainant, the claim was referred to a Dr.M.A.Kamath, Medico Legal Consultant, for an independent medical opinion, who opined that the Complainant had mild Cervical Spondylosis and in such cases traction was not required. Further traction of the neck does not require hospitalization and therefore as per the terms and conditions of the Policy Part-E does not cover any sickness related to the claims mentioned therein. The Complainant was hospitalized following pain in the neck which is a sickness related condition not covered under the policy, therefore the claim is rightly repudiated and the Complainant is not entitled for any claim and sought for dismissal of the complaint.
III. 1. In support of the complaint, Percy Noel Pias (CW1) – Complainant filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on him and got marked Ex C-1 to C-8. One Sri Alok Kumar Gupta, Senior Manager Claims of Opposite Party (RW-1) filed affidavit and got marked as Ex.R-1 to Ex.R-4.
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 the Opposite Party has committed deficiency in service?
- If so, whether the Complainant is entitled for the reliefs claimed?
- What order?
We have considered the notes/oral arguments submitted by the learned counsels and also considered the materials that was placed before this Forum and answer the points are as follows:
Point No.(i): Affirmative.
Point No.(ii) & (iii): As per the final order.
REASONS
IV. 1. POINTS NO. (i) TO (iii):
In the mentioned case, the facts which are admitted that the Complainant obtained the policy bearing No.0250042061and valid from 13.10.2011 to 22.10.2011. It is also not in dispute that the complainant visited Govt. Community Hospital for the treatment of acute neck pain which was diagnosed as cervical C5 and C6 Spondylosis.
Now the points are in dispute between the parties before this Fora is that the Complainant contended that he had admitted to the Govt. Community Hospital for the treatment of acute Neck Pain which was diagnosed as cervical C5-C6 Spondylosis and got admitted from 13.10.2011 to 22.10.2011 as per the advice of the treating doctor and spent Rs.50,000/- but the Opposite Party not reimbursed the claim. Hence the complainant came up with this complaint.
On the contrary the Opposite Party relied the policy terms and conditions, Part E which reads thus:
We will pay a Daily Benefit for each Day You are an inpatient in a Hospital due to Injury subject to any applicable Deductible shown in the Policy Schedule and commences under the circumstances described in a Hazard and while this Policy is in effect. The Period of Confinement must be Medically Necessary and recommended by a Physician. The total benefits provided for any one Period of Confinement are subject to the In-Hospital maximum shown in the Policy Schedule.
The Daily Benefit will be paid at the rate shown on the Schedule of Benefits if You are admitted to a Hospital, in the Republic of India, as an inpatient as a result of a covered injury.
As per the above terms and conditions, the policy does not cover any sickness related claims. Cervical Spondylosis which is a sickness related condition not covered under the policy.
On perusal of the oral as well as documentary evidence available on records, we are of the considered opinion that the Complainant in this case admittedly had some problems related to the neck and consulted a doctor attached to the Government Community Hospital for treatment. The doctor diagnosed as Cervical C5-C6 Spondylosis and advised the Complainant to get admitted to the hospital. However, on perusal of the medical records it reveals that the Complainant got admitted to Govt. Community Hospital but no medical bills produced for the reimbursement of the medical expenses. The discharge slip produced by the Complainant shows that the Complainant got admitted on 13.10.2011 and got discharged on 22.10.2011 but no medical bills produced in order to claim the relief sought by the Complainant. Without the medical bills the complaint filed by the Complainant cannot be considered and the same has no basis deserves to be dismissed.
In the light of the above, we pass the following:
ORDER
The complaint is dismissed. No order as to costs.
Copy of this order as per statutory requirements, be forward to the parties and file shall be consigned to record room.
(Page No.1 to 6 dictated to the Stenographer typed by him, revised and pronounced in the open court on this the 31st day of May, 2016).
PRESIDENT MEMBER
(SMT. ASHA SHETTY) (SMT. LAVANYA M.RAI)
D.K. District Consumer Forum D.K. District Consumer Forum
Mangalore. Mangalore.
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 – Percy Noel Pais – Complainant.
Documents produced on behalf of the Complainant:
Ex C1 – Copy of the Insurance Policy
Ex C2 – Office Copy of the Lawyer’s Notice
Ex C3 – Letter issued by the Postal Authority.
Ex C4 – Doctor’s Certificate
Ex C5 – Outpatient Receipt
Ex C6 – Inpatient Case Sheet
Ex C7 – Clinical Chart of temperature
Ex C8 – Laboratory Report.
Witnesses examined on behalf of the Opposite Parties:
RW-1: Alok Kumar Gupta, Senior Manager Claims of Opposite Party.
Documents produced on behalf of the Opposite Parties:
Ex R1 – Original Policy Condition
Ex R2 – Medico-Legal Report filed by Dr.M.S.Kamath
Ex R3 – Letter dated 09.01.2012 issued to the complainant by the OP.
Ex R4 – Reply notice dated 13.06.2012 issued by the OP.
Dated:31-05-2016 PRESIDENT
