BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE
Dated this the 9th January 2017
PRESENT
SRI VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SRI T.C. RAJASHEKAR : HON’BLE MEMBER
ORDERS IN
C.C.No.106/2013
(Admitted on 5.04.2013)
Mrs. Joy Jeevan Rai,
Wife of Jeevan Rai,
Aged 49 years,
Residing at Anurag, Kuntikhan,
Bejai Post, Mangalore.
….. COMPLAINANT
(Advocate for the Complainant: Sri AKU)
VERSUS
1. The Branch Manager/Assistant Manager,
United India Insurance Company Ltd.,
Regd & Head Office 24, Whites Road,
Chennai 60014.
2. The Senior Divisional Manger,
United India Insurance Company Ltd.,
Bancassurance Division: 3.5.817, 7th Floor,
United India Towers, Basheerbagh,
Hyderabad 500029.
3. The Manager,
M/s Good Health Plan Ltd,
Plot No.49, Nigarjuna Hills,
Panjagutta, Hyderabad 500 082.
…......OPPOSITE PARTIES
(Advocate for the Opposite parties No.1 & No.2: Sri DRK)
(Opposite parties No.3: Ex-parte)
ORDER DELIVERED BY HON’BLE PRESIDENT
SRI. VISHWESHWARA BHAT D:
I. 1. The above complaints filed under Section 12 of the Consumer Protection Act by the same complainant against same opposite parties alleging deficiency in service against opposite parties claiming certain reliefs.
The brief facts of the case are as under:
On the offer of opposite party No.1 and No.2 of Health insurance coverage complainant purchased medi claim Health insurance policy for the period covered from 15.6.2011 to 14.6.2012 with A.J. Hospital, Mangalore as one amongst approved network hospitals provided under the policy. During the validity of the policy complainant fell ill and was admitted to A.J. Hospital, Mangalore as inpatient on 17.8.2011 and on the advice of Dr.Virnda Shetty she underwent hysterectomy on 25.8.2011 was discharged on 31.8.2011 and for the hospitalization bill of Rs.47,991.70. As per the terms of the policy the complainant is entitled for indemnification of 20% of the sum insured for the paid by opposite party directly to the hospital. Under the policy condition 5.1(f) the complainant is also entitled for Pre and Post Hospitalization expenses in actual, subject to a maximum of 10% of the sum insured of the total sum. The complainant paid Rs.27,992/ at the time of discharge and liable to be reimburse by the opposite party as per the said policy condition5.1(f). Out of paid of Rs.10,000/ to complainant the claim laid by complainant on 13.10.2011 was repudiated by letter dated 22.10.2011 on untenable ground. Contending that there is deficiency on the part of opposite party seeks the complainant claimed relief as opposite parties failed to make payment despite the legal notice dated 13.02.2013.
II. The opposite parties written version admitting the medi claim policy issued to complainant during the period mentions and receipt of claim in respect of inst on found on complainant and payment of Rs.20,000/ mentioned in the complaint. The claim dated 13.10.2011 for Rs.27,992/ was repudiated as the maximum amount passed in the previous claim. The entitlement of 10% for sum assured for Pre and Post is also denied hence seeks dismissal.
2. In support of the above complainant Mrs. Joy Jeevan Rai filed affidavit evidence as CW1 and answered the interrogatories served on her and produced documents marked Ex.C1 to C9 detailed in the annexure. On behalf of the opposite parties Mr. Amar Kumar Sinha (RW1) Divisional Manager also filed affidavit evidence and answered the interrogatories served on her and produced document marked Ex.R1 detailed in the annexure.
In view of the above said facts, the points for consideration in the case are:
- Whether the Complainant is a consumer and the dispute between the parties?
- If so, whether the Complainant is entitled for any of 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): Negative
Point No.(iii): As per the final order.
REASONS
POINT NO.(i): In this case the opposite party issued the insurance policy covering risk to complainant under the medi claim policy Ex.C1 is admitted by bother sides. However the complainant claims under clause 5.1(f) of Ex.C1 she is entitled for pre and post hospitalization expenses of a maximum limit of 10% of the sum insured. This however is disputed by opposite parties. Hence there is a live dispute between the complainant the consumer and the opposite parties the service provider as contemplated under the C P Act. Hence point No.1 answered in the affirmative.
POINT NO.(ii): It is referred directly to clause 5.1 c under which 20% of is subjected to i.e. Rs.20,000/ admittedly paid to complainants hospitalization expenses directly to hospital by opposite parties. Relevant 5.1 (3) (c) and (f) of the policy reads:
3. Hospitalisation expenses limited to:
c) Hysteretomy: 20% of SI subject to max of Rs.50,000/-
d)
e)
f) Pre and Post Hospitalisation Expenses: Actual subject to a maximum of 10% of the sum insured.
Ongoing through above two provisions, the complainant having already got the benefit under the 5.1 3 (c) is now seeking benefit under 5.1.3(f). The definitions of the word pre exist is previous existing as verified from the definition pre exist from Google search: is existing or present earlier or before a certain point of time. Similarly the word ‘post exist’ means to exist at a later time, especially after the post.
2. In the case on hand the words used in 5.1 3(f) are pre and post hospitalization expences which according to us must mean the expences incurred before and after the hospitalization and does not mean the procedure of Hysteretomy alone. According to the complainant the hospitalization of the complainant was from 17.8.2011 to 31.8.2011. There are no documents produced by complainant of any expences incurred towards treatment either prior to this hospitalization on 17.8.2011 or subsequent to discharge from hospital on 31.8.2011. In our considered view the expences incurred prior to 17.8.2011 and subsequent to discharge on 31.8.2011 are only covered under clause 5.1.3(f) of Ex.C1. Having said that there have been no documents to show any such expences incurred by complainant during the period excluding 17.8.2011 and 31.8.2011 the claim of complainant is not maintainable. Hence point No.2 answered in the negative.
POINTS No. (iii): Wherefore the following order
ORDER
The complaint is dismissed.
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 6 directly dictated by President to computer system to the Stenographer typed by her, revised and pronounced in the open court on this the 9th January 2017)
MEMBER PRESIDENT
(SRI T.C. RAJASHEKAR) (SRI 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. Joy Jeevan Rai
Documents marked on behalf of the Complainant:
Ex.C1: Mediclaim Insurance Policy
Ex.C2: Discharge summary issued by A.J. Hospital
Ex.C3: Final bills issued by A.J. Hospital
Ex.C4: 12.10.2011 Repudiation letters issued by O.P
Ex.C5: 13.2.2013 Legal notice issued to the O.P
Ex.C6: Postal Receipts issued by Postal authority
Ex.C7: Acknowledgement Card
Ex.C8: Acknowledgement Card
Ex.C9: Letters dated 30.8.2011 issued by Dr. Vrinda Shetty of J. Hospital Research Centre.
Witnesses examined on behalf of the Opposite Parties:
RW1 Mrs. Sujatha, PDO, Mundoor
Documents marked on behalf of the Opposite Parties:
Ex.R1: Policy Copy
Dated: 09.01.2017 PRESIDENT
