BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE
Dated this the 22nd March 2017
PRESENT
SRI. VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SRI. T.C. RAJASHEKAR : HON’BLE MEMBER
ORDER IN
C.C.No.236/2014
(Admitted on 7.7.2014)
Mrs. Savitha,
W/o Santhosh Kumar,
Aged about 27 years,
R/o yashovishwa, Near Bus Stand,
Talapady, Mangalore 575023.
….. COMPLAINANT
(Advocate for the Complainant: Sri JRN)
VERSUS
- Mr. Venkataswamy K,
CRM Medi Assist. India TPA Pvt. Ltd,
No.1.10.74, Flat No. G.201,
2nd Floor, Galada Towers,
Survey No.44, Vile Bapuji Estate,
Begumpet, Hyderbad 500016.
- M/s Oriental Insurance Company Ltd,
6-3-871, Snehalata, Greenland Road,
Begumpet, Hydarbad 500016,
- M/s. Agrigold Connstruction Private Ltd.
Volapete, Thokkottu, Mangalore Taluk.
….OPPOSITE PARTIES
(Opposite Party No.1 and 3: Ex parte)
(Advocate for the Opposite Party No.2: Sri. AKK)
ORDER DELIVERED BY HON’BLE MEMBER
T.C. RAJASHEKAR:
I. 1. The above complaint filed under Section 12 of the Consumer Protection Act alleging deficiency in service against the Opposite Party claiming, to pay a sum of Rs.34,000/, to pay a sum of Rs.5,000/ towards mental agony, to pay cost Rs. 5,000/.
2. In support of the above complaint Mrs. Savitha, filed affidavit evidence as CW1 and answered the interrogatories served on her and produced documents got marked at Ex.C1 to C7 as detailed in the annexure here below. On behalf of the opposite parties Raghu Naik, (RW1) Assistant Manager, 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 of the parties. This dispute is in respect of the mediclaim policy alleged to have been taken by the employer of the complainant and on claiming the amount of delivery expenses the opposite party not responded. The complainant alleges that the he is the employee of the opposite party no 3 and the employer has obtained an insurance policy to cover the benefit of delivery expenses. The complainant on admitting of the hospital and delivered the child
And submitted the bill for the same with the opposite party no 1. The opposite party no 1 has tie-up with the opposite party no 2 and there is no response from the Opposite parties to the claim made by the complainant. The opposite party no 1 and the opposite party no 3 placed ex-parte. The opposite party no 2 filed version and contended that the complainant not produced any claim or bills or even policy details to honor the claim and states that if the policy copy with details is submitted they are ready to consider as per policy condition. Since no claim made with them there is no question of deficiency in service on their part. These are being the facts of dispute in resolving it we consider the following.
POINTS FOR ADJUDICATION
We have considered the evidence produced and the documents produced by the parties. The complainant not produced the policy copy with terms and conditions. The opposite party no 2 only contesting party denies having issued any insurance policy to the complainant or his employer opposite party no 3, and denies that the complainant submitted any claim or any documents to them. It is also denied by opposite party no 2 the hospitalization, delivery and the expenses met. There is no admissions. This being the facts we consider the following points in resolving this dispute.
- Whether the complainant is a consumer under the consumer protection 1986?
- Whether the deficiency in service against the opposite party is proved by the complainant?
- Whether the complainant is entitled for the relief prayed for?
- What order?
We have closely examined the evidence and the documents produced. Traversed through the notes filed by the parties and heard the submissions of the counsels and answered the above points as under:
- In the affirmative against opposite party no 1 only.
- In the affirmative against the opposite party no 1 only
- In the affirmative.
- As per delivered order
REASON
POINT NO.1: The complainant had produced EX C 6, purported to be issued by the opposite party no 1 MEDI EAST INDIA TPA Pvt. Ltd. with MA ID 4012250192. Which shows the complainant name as Savita. Hence we drawn a conclusion that the complainant had availed a service through her employer Agri Gold Pnt. Ltd. which established the relation of consumer and the service provider between the complainant and the opposite party no 1. But in relation to opposite party no 2 and 3 there is no any documents to show the relation. It is admitted that the opposite party no 3 is the employer and not the service provider. Hence we answered the point no 1 in the affirmative against the opposite party no 1 only.
POINT NO. 2: The complainant alleged the deficiency in service on the part of the Opposite parties on the ground of the Mediclaim insurance policy issued by the Opposite parties not honored when the claim submitted. So it is the burden of the complainant to prove the deficiency in service on the part of the opposite parties. The complainant had produced only an EX C 6 which displays the name of the opposite party no 2 as heading and shows details like, MA ID No as 4012250192, complainant name, Pol holder as opposite party no 3, employee no CN 0203 valid up to 26.04.2013. looks like having written as Serviced by MEDI EAST INDIA TPA Pvt. Ltd. (Xerox not visible clear, original not produced). In the reverse side of the card it is stated that, This card is only identification purpose and is not an authorization to proceed with the treatment or a guarantee for payment it is also written that it is subject to the terms and condition of the underlying insurance policy enables you to avail cash less facility on the basis of the preauthorization issued by Medi asst. As per contents it seems like an health card issued by the opposite party no 1 to the complainant but it is subject to policy conditions.
In our opinion this documents alone will not establish the complainant case. Unless the complainant produced the policy copy to show that the policy is issued by the opposite party no 2 we cannot hold either the policy is issued or the delivery expenses covered or the opposite party no 2 not honored the claim. It is also admitted through interrogatories served on the complainant by the opposite party no 2 that the complainant not submitted any bill or claim form with the opposite party no 2. The complainant states that he has submitted the claim and the bills to the opposite party no 1. The opposite party no 1 not participated in the proceedings and placed ex parte. As far as the opposite party no 2 is concerned the complainant not produced any documents or evidence to show that the opposite party no 2 issued the insurance policy and that insurance policy covered the delivery expenses, and the opposite party no 2 not settled the claim.
However the health card produced by the complainant show that there is a policy and it is valid up to 26.04.2013 which is issued by the opposite party no 1 is enough to draw a conclusion on circumstance that the opposite party no 1 had covered the complainant with a health policy. In our opinion it is the opposite party no 1 who has to settle primarily the claim of the complainant. Hence the opposite party no 1 is to be held of the deficiency in service and we answered the point no 1 in the affirmative against the opposite party no 1 only.
POINT NO 3: As per above discussion we hold the opposite party no 1 is liable for deficiency in service and he has not appeared before us and controverted the allegations against him or produced any evidence to prove his case. It is inferred that the opposite party no 1 admitted the allegations against him. Hence the complainant is entitled for the relief of the payment of Rs.34,000/ with an interest of 9% per annum from the date of complaint till the date of payment and an amount of Rs.5,000/ towards compensation and Rs.5,000/ towards cost from the opposite party no 1 only. The opposite party no 2 and 3 are discharged from the liability.
POINT NO. 4: In the light of above discussion and adjudication of the above points we deliver the following
ORDER
The complaint is allowed. The opposite party no 1 shall pay the complainant an amount of Rs. 34,000/ (Rupees Thirty Four thousand only) with an interest of 9% per annum from the date of complaint till the date of payment and an amount of Rs.5,000/(Rupees Five thousand only) towards compensation and Rs.5,000/(Rupees Five thousand only) towards cost within 30 days from the 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 7 directly typed by Member, revised and pronounced in the open court on this the 22nd 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 Mrs. Savitha,
Documents marked on behalf of the Complainant:
ExC1: 25.9.2012: Copy of Discharge summery.
Ex C2: 21.3.2013: Copy of Medical bill issued by the Mangalore Nursing Home along with payment made towards Doctors (2 receipts).
Ex C3: 30.3.2013: Receipt for having sent the claim through speed post to Opposite Party.
Ex.C4: 08.7.2013: office copy of Lawyers Notice.
Ex.C5: 19.7.2013: Acknowledgement card for having received the document No.4 above.
Ex.C6: Notarized copy of card issued by the 1st Opposite Party.
Ex.C7: 28.3.2014: Copy of Order in complaint No.352/2013 passed by the Hon’ble Forum.
Witnesses examined on behalf of the Opposite Party:
RW1: Raghu Naik, (RW1) Assistant Manager
Documents marked on behalf of the Opposite Party:
Nil
Dated: 22.03.2017 MEMBER
