BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 31st MARCH 2016
PRESENT
SMT. ASHA SHETTY : HON’BLE PRESIDENT
SMT.LAVANYA M. RAI : HON’BLE MEMBER
COMPLAINT NO.115/2013
(Admitted on 27.04.2013)
Smt. Seetha
W/o. Late Krishnappa gowda,
Aged about 35 years,
R/at Mangila Padavu House,
Idkidu Village and P.O.
Bantwal Tq, D.K. …….. COMPLAINANT
(Advocate for Complainant: Sri. Sanjay D)
VERSUS
1. Project Officer,
Shree Kshethra Dharmasthala,
Gramabivriddi Yojane,
Dharmasthala Building,
Puttur Branch,
Puttur.D.K.
2. Divisional Manager,
The National Insurance Company Road,
Mangalore. D.K.
……OPPOSITE PARTIES
(Advocate for Opposite Party No 1 : Sri. Udaya Kumar Shetty)
(Advocate for Opposite Party No 2 : Sri. A.L. Shenai)
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 along with 5 family members became the members of Sampoorna Surksha yojana scheme in the year 2012-13. As per the scheme the complainant is entitled sum of Rs. 60,000/-. When the matter stood thus the complainant’s husband Krishappa Gowda admitted to KMC Hospital Attavar on 20.10.2012 for cirrhosis of liver with portal HTN and after the treatment he was discharged on 27.10.2012 and spent Rs. 39,348/- for the medical expenses. Thereafter once again admitted to Danwanthari hospital Puttur on 01.11.2012 discharged on 05.11.2012 and spent of Rs. 5,830/. It is stated that since the patient’s condition was serious he expired on 23.11.2012 and again spent Rs. 6,395. It is stated that complainant submitted the claim to the opposite parties, but the opposite parties not settled the claim till this date. Hence the complainant filed the above complaint under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this FORA to the Opposite Parties to pay a sum of Rs.51,573/- along with interest, compensation and cost of the proceedings.
II. 1. Version notice served to the Opposite Parties and the Opposite Parties appeared through their counsels filed version. The Opposite Party No. 1 stated that, the complainant was fully aware of the scheme and she was well educated about the Sampoorna Surksha Yojana scheme. Whoever member who form a part of a group were made known of the said scheme. The Mahiti Patra is issued and it contains the network of listed hospitals under which the treatment can be taken and disease that are covered. The opposite party has issued membership card along with ID card also Mahiti Patra. It is stated that the disease which the complainant husband had taken is not covered under the policy and thereby national insurance company rejected the claim. This opposite party denied the deficiency and sought for or the dismissal of complaint.
The 2nd Opposite Party filed a version stated that the diseases for which her husband had taken treatment is not covered under the policy. It is further stated that complainant husband was a Chronic Alcoholic and the disease which is suffering is on account of excessive drinking which is not covered under the policy and sought for dismissal of the complaint.
III. 1. In support of the complaint, Smt Seetha (CW1) – Complainant filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on her and produced Ex. C1 to C12. One Sunitha Nayak (RW-1) of Opposite Party No. 2 adopts the evidence of Opposite Party No. 1 filed counter affidavit and answered the interrogatories served on them. EX-R-1 to R-3 were marked for the Opposite Parties.
In view of the above said facts, the points now that arise for our consideration in this case are as under:
(i) Whether the Complainant proves that the Opposite Parties have committed deficiency in service?
(ii) 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 answered 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):
The facts which are admitted is that the complainant along with her 5 family members insured under the scheme Sampoorna Surksha Yojana as per membership No: 3171365 for the year 2012-13. It is also not in dispute that complainant’s husband Krishnappagowda was admitted to KMC Hospital Attavar Mangalore on 20.10.2012 for Cirrhosis of liver with portal HTN and discharged on 20.07.2012. It is also not in dispute that the complainant’s husband again admitted to Danavanthary hospital Puttur on 1.11.2012 and discharged on 5.11.2012 and thereafter with aquite hepatic failure he expired on 23.11.2012.
The complainant contended that her husband died on 23.11.2012 due to ill-health and he is covered under the Sampurna Suraksha Yojana Medical insurance. But the opposite parties repudiated the claim which is not justifiable.
The opposite parties on the contrary contended that the complainant husband Chronic Alcoholic it is not covered under the policy.
On perusal of the oral as well as documentary evidence available on record, it is seen that the 1st opposite party has impleaded 2nd opposite party i.e. National Insurance Company during the pendency of this complaint. The Ex C-1 is membership receipt issued by the 1st opposite party which shows that complainant and her family covered under the scheme.
However, the 1st opposite party took a defense that they have received the amount from the complainant and part of the amount paid to the 2nd opposite party i.e. national Insurance Company. But it is very surprised to note that the 1st opposite party not produced any insurance policy before this FORA obtained by them. It is not correct on the part of the 1st opposite party to conceal insurance policy with the consumers/complainant herein inspite of taking premium. However we do not want to comment on this issue as the insurance company is admitted that the complainant and her family insured with them. It is the responsibility of the insurance company to take a debate with opposite party No. 1 not by the complainant.
The defense of the opposite party No. 2 that the complainant husband is Chronic Alcoholic and not covered under the policy. Except the bare statement nothing has been placed on record to show that the complainant’s husband died due to chronic Alcoholic. On the other hand the hospital record produced by the complainant i.e. EX C-5 shows that the complainant was undergone treatment for Cirrhosis of liver with portal HTN, but no terms and conditions of the policy produced by the insurance company to show that the above disease is not covered under the policy. In the absence of the same, the opposite party No. 2 is liable to pay the insurance to the complainant in this case. The repudiation made by the opposite parties is without any basis and which amounts to deficiency in service.
Since there is no insurance contract with the opposite party No. 1, the question of deficiency does not arise, because the opposite party No. 2 admitted that the complainant and her family are covered under the policy. Therefore, complaint against opposite party No 1 is hereby dismissed.
Under the above reasons, we hereby directed the Opposite No. 2 to pay Rs. 51,573/- along with interest @ 10% p.a. from the date of complaint till the date of payment and also pay Rs. 3,000/- as cost of litigation expenses. Payment shall be made within 30 days from the date of receipt of this order.
In the result, we pass the following:-
ORDER
The complaint is allowed. Opposite No. 2 shall pay Rs. 51,573/- along with interest @ 10% p.a. from the date of complaint till the date of payment and also pay Rs. 3,000/- as cost of litigation expenses. Payment shall be made within 30 days from the date of receipt of this order.
Complaint against opposite party No. 1 is hereby by dismissed.
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 dictated to the Stenographer typed by him, revised and pronounced in the open court on this the 31st day of MARCH- 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 – Smt. Seetha – Complainant.
Documents produced on behalf of the Complainant:
Ex C1: 01.04.2012: Copy of the membership receipt
for the year 2012-13.
Ex C2: 25.10.2012: Copy of the USG abdomen and Pelvis.
C3:C3: 20.10.2012: Copy of the Gastro-Duodenoscopy Report.
Ex C4: 27.10.2012: Copies of the bills (2).
Ex C5: 26.10.2012: Copy of the discharge summary of
KMC Hospital.
Ex C6: 05.11.2012: Copies of the bills (6).
Ex C7: 05.11.2012: Copy of the Discharge summary
of Dhanvanthary Hospital.
Ex C8: 23.11.2012: Copies of the bills(9).
Ex C9: 23.11.2012: Copy of the Discharge summary
of Dhanvanthary Hospital.
ExC10:12.12.2012: Copy of the death certificate.
ExC11:18.01.2013: Office copy of the regd lawyer’s notice.
ExC12:31.01.2013: Reply of the Opposite Party.
Witnesses examined on behalf of the Opposite Parties:
RW-1: Sunitha Nayak, -Opposite Parties
Documents produced on behalf of the Opposite Parties:
Ex-R-1: Original Mahithi Patra.
Ex-R-2: Copy of the application to enroll in Sampoorna
Suraksha(original).
Ex-R-3: Attested copy of Policy together with Schedule.
Dated:31-03-2016 PRESIDENT
31.03.2016.
ORDER
The complaint is allowed. Opposite No. 2 shall pay Rs. 51,573/- along with interest @ 10% p.a. from the date of complaint till the date of payment and also pay Rs. 3,000/- as cost of litigation expenses. Payment shall be made within 30 days from the date of receipt of this order.
Complaint against opposite party No. 1 is hereby by dismissed.
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 dictated to the Stenographer typed by him, revised and pronounced in the open court on this the 31st day of MARCH- 2016).
PRESIDENT MEMBER
(SMT. ASHA SHETTY) (SMT. LAVANYA M.RAI)
D.K. District Consumer Forum D.K. District Consumer Forum
Mangalore. Mangalore.
