BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE
Dated this the 30th May 2017
PRESENT
SRI VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SRI T.C. RAJASHEKAR : HON’BLE MEMBER
ORDERS IN
C.C.No.274/2013
(Admitted on 11.10.2013)
Mr. Chandrashekar Shetty,
Aged about 55 years,
S/o Subbayya Shetty,
Chowki House, Badaje Post,
Manjeshwar, kasaragod District,
Kerala 671323.
….. COMPLAINANT
(Advocate for the Complainant: Sri ANN)
VERSUS
- T.T.T.K. Health Care Pvt. Ltd,
City plaza, 2nd Floor,
No.201,202,203 KRR Road,
Shedigudda, Near PVS Circle,
Mangalore 575003
Represented by its Authorised Signatory.
- The Branch Manager,
United India Insurance Co.Ltd,
Opp. Popular Building,
KS Rao Road, Mangalore 575001.
…......OPPOSITE PARTIES
(Opposite Party No.1: Ex parte)
(Advocate for the Opposite Party No.2: Sri. DRK)
ORDER DELIVERED BY HON’BLE MEMBER
SRI T.C. RAJASHEKAR:
I. 1. The above complaint filed under Section 12 of the Consumer Protection Act 1986 alleging deficiency in service against the Opposite Party claiming, to pay Rs.20,000/ towards the medical expenses incurred, to pay the interest thereon from the date of accident i.e. from 11.3.2013 till deposit, to pay Rs.5,000/ towards cost, to pay compensation of Rs.10,000/ towards mental agony caused to the complainant.
2. In support of the above complaint the complainant Mr. Chandrashekar Shetty, filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked at Ex.C1 to C5 as detailed in the annexure here below. On behalf of the opposite parties Mr. Amar Kumar Sinha, (RW1) Divisional Manager, also filed affidavit evidence and Mr. Pundalika Nayak, answered the interrogatories served on him.
The brief facts of the case are as under:
We have perused the complaint and the version. The dispute is with regard to repudiation of mediclaim. The complainant alleges that he had obtained a family policy and his wife admitted to hospital and treated. On submitting the claim the opposite party repudiated the claim on the ground that for the treatment hospitalization was not necessary. The complainant states that, only on the advice of the hospital doctor the admission was made. Hence alleges the deficiency in service on the part of the opposite parties. The opposite party contended in their version that, after verifying the terms and the condition of the policy and the documents submitted by the complainant, the opposite party settled the claim of the complainant for a sum of Rs.15,047/ and enclosed a cheque bearing No 317369 dated 29.11.2013 drawn in favour of the complainant but the complainant without any just cause and reason refused the same. These are being the facts of dispute we are of the view to decide the following
POINTS FOR ADJUDICATION
We have examined the evidence and the documents produced by the parties. The admitted facts material to the dispute are, the issue of the health policy, the admission to the hospital and the treatment in the hospital. The submission of the claim papers to the opposite parties. It is admitted by the opposite parties that they have after considering the documents and the terms and condition of the policy they have allowed a claim of Rs.15,047/. It is denied by the complainant that the opposite party had allowed the claim and offered. Rs. 15,047/ through cheque and denial to accept the claim by him. The opposite party denies the complainant has submitted all the documents for settling the claim. Admissions and denials reconciled and the following points are taken for consideration in resolving this dispute.
- Whether the complainant is the consumer under the consumer protection Act 1986?
- Whether opposite party proves the claim settlement is proper and offered the same to the complainant and no deficiency in service on the part of the opposite parties?
- Whether the complainant is entitled for the relief prayed for?
- What order?
We had a close observation on the file documents and evidence lead by the parties. Heard the party submissions and answered the points as under:
- In the affirmative.
- In the negative.
- In the affirmative.
- As per delivered order.
REASON
POINT NO 1: The complainant produced the health insurance policy No 070801/48/12/14/00000923 as EX C 1(second sheet) which is issued in the name of the complainant herein. The issue of the policy is not disputed by the opposite parties. Hence we answered the point no 1 in the affirmative.
POINT NO 2: The complaint allegation is the opposite party not settled the claim in spite of submitting the claim papers with bills and other documents. The opposite party contention is, they have considered the claim on the base of the documents produced and the terms and condition of the policy and offered Rs.15,047/ and offered the same through cheque to the complainant but the complainant refused to accept. Now it is admitted by the opposite party that, the claim is not repudiated. The contention of the opposite parties that the treatment could have been done on outpatient basis does not have life. The dispute to be decided is, whether the opposite party is justified in allowing only Rs.15,047/ as allowable claim as per documents produced and as per policy condition? And is it true that the opposite party offered Rs. 15,047/ to the complainant and he has refused the same to accept? So we decided to adjudicate the point No.2.
2. On study of the case file we did not find any documents produced by the opposite party. There is no document to show the claim of the complainant settled as per terms & conditions and the based on the documents produced. It is admitted that the complainant had submitted the claim with the medical bills and there is no documents to show further bill or documents sought by the opposite party from the complainant for settling the claim. It is also born by record that the claim of the complainant is allowed. The opposite party not given any justification for their allowing of Rs. 15,047/ only and even though the complainant produced all related documents which is admitted facts the opposite party not come out with any details with regard to expense bills which are not acceptable as per terms & conditions.
3. We have considered the evidence of interrogatories served by the complainant on the opposite party. As per Question No 3 the opposite party personally verified the medical records submitted by the complainant. As per Question No 10 and 11 the opposite party has contended that he is ready to pay the amount but not produced any document having made an effort to pay by producing the copy of the cheque drawn in favour of the complainant or any claim allowed document. Also the opposite party not deposited any amount in the Forum. The question No 14 the answer is ambiguous. On one breath the opposite party says they have allowed the claim and in another breath opposite party says it is true they have repudiated.
4. By considering all the above facts we are of the view that the opposite party has not applied their mind properly in appreciation of the claim documents submitted by the complainant and unilaterally without any justification arrived at the figure of Rs.15,047/ as the claim amount which is not acceptable to this Forum. The valuation of the claim is not justified and proper. Hence the answer to the point no 2 is in the negative.
POINT NO 3: The opposite party has not acted properly in settling the claim of the complainant and hence liable to pay the mediclaim amount to the complainant. The complainant sought for an amount of Rs. 20,000/ towards medical expenses and submits that, the bills are submitted to the opposite parties. The opposite party not denied the submission of the bills. There is no record in the file to assess how much is the actual bill amount. The opposite parties have not submitted any details of bills submitted and the claim allowed. In this
of situation we are with only option to allow what the complainant claimed in the prayer as medical treatment expenses. Hence in our opinion the complainant is entitled for an amount of Rs. 20,000/ with an interest of 9 % per annum from the date of complaint till the date of payment and an amount of Rs.5000/ towards compensation and Rs.8,000/ as litigation expenses.
POINT NO 4: In the light of the above discussions and the adjudication of above points we deliver the following
ORDER
The complaint is allowed. The opposite parties shall pay the complainant jointly and severally an amount of Rs.20,000/ 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.8,000/ towards cost within 30 days from the date of the copy of this order received.
On failure to comply the opposite party shall pay an additional interest at the rate of 2 % per annum from the date of complaint till the date of payment.
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 7 directly typed by Member, revised and pronounced in the open court on this the 30th May 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 : Mr. Chandrashekar Shetty
Documents marked on behalf of the Complainant:
Ex.C1: Synd Arogya Group Mediclaim policy from Opposite Party No.2 vide policy bearing No.070701/48/12/14/00000923 valid from
19.8.2012 to 18.8.2013.
Ex.C2: Copy of Discharge summary issued by Mangala Hospital.
Ex.C3: Copy of claim repudiation letter of Opposite Party dated 19.3.2013.
Ex.C4: Office copy of legal notice sent to opposite parties dated 6.8.2013 with postal receipts and acknowledgements.
Ex.C5: Reply of Opposite Party No.2 dated 12.8.2013.
Witnesses examined on behalf of the Opposite Parties:
RW1: Mr. Amar Kumar Sinha, (RW1) Divisional Manager
Documents marked on behalf of the Opposite Parties:
Nil
Dated: 30.5.2017 MEMBER
