BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE

Dated this the 4^th October 2016

PRESENT

        SMT. C.V. SHOBHA             :  HON’BLE PRESIDENT 

        SMT.LAVANYA M. RAI        :   HON’BLE MEMBER                                         

COMPLAINT NO. 94/2014

(Admitted on 15.03.2014)

       K. Sadananda Aithal,

       S/o K. Mahabala Aithal,

       Aged about 54 years,

       R/at Narimogru, Shibara Post,

       Puttur Taluk, D.K.

                                                                        …….. COMPLAINANT 

(Advocate for Complainant: Sri SD)

VERSUS

1.    The Manager,

       National Insurance Co. Ltd.,

       1^st Floor, Dharmasthala Building,

       Main Road, Puttur, D.K.

2.    The Manager,

       Dedicated Healthcare Services,

       TPA (India) Pvt. Ltd.

       25.8.497, 1(2), 1^st Floor,

       Arjun Anjali Compound,

       Opp. to Shiva Restaurant, Gorigudda,

       Valencai, Mangalore  02.

                                               ……OPPOSITE PARTIES

 (Advocate for Opposite Party No.1: Sri ALS)

 (Opposite Party No.2: Ex parte)

ORDER DELIVERED BY HON’BLE PRESIDENT 

SMT. C.V. SHOBHA

1. 1. This complaint is filed under section 12 of the Consumer Protection Act alleging deficiency of service as against the opposite parties claiming certain reliefs.

       2. The complainant prays for the order for reliefs directing the opposite parties to pay Rs.13, 335/ with 12% interest from 31/03/2013 till payment, to pay a sum of Rs.20,000 towards compensation, to pay Rs.10,000 towards  expenses and such other further suitable relief’s  to be granted as the Forum deems fit under the circumstances of the case.

II.           The brief facts of the case are as under:

The top Number Complaint lodged by the complainant against the above of the opposite party Under Section 12 of Consumer Protection Act for the relief as sought for, on the strength that the complainant along with his wife and daughter are the holder of Individual Mediclaim Policy of the 1^st opposite party as per No. 602301/48/12/8500001018 for Rs.1,50,000/ i.e. each individual is entitled for a sum of Rs. 50,000/ each.  The policy is valid from 17.12.2012 to 16.12.2013.  The complainant has paid Rs. 3,170/ as premium to the above policy and the 2^nd opposite party is the TPA of the 1^st opposite party. Further, the matter stood thus the complainant’s wife Smt. Poornima S. Aithal was admitted to the Dhanvanthari Hospital Puttur on 23.03.2013 for vault Prolapse and was operated on the same day and was discharged on 31.03.2013.  The complainant has spent Rs. 38,455/ for the operation. After the operation the complainant has submitted the claim form along with original of bills, lab reports and discharge summary to the opposite parties and the opposite parties have paid Rs. 25,120/ towards the claim on 19.07.2013.  Hence the complainant got issued registered. Lawyers notice dated 23.08.2013 to the opposite parties and the notices was served on the opposite parties on 26.08.2013 and 24.08.2013 respectively without demur. Further submitted that the 1^st opposite party has served one and half page of the policy to the complainant and as per the policy served, the complainant is entitled for Rs. 1,50,000/.  Further it is submitted that the opposite parties have not served conditions of the policy to the complainant.  Further without serving conditions the opposite parties cannot deduct any amount from the final bill. Hence paying a part of the claim to the complainant amounts to deficiency of service by the opposite parties.  Further the opposite parties are duty bound to reimburse the expenses of the treatment from admission of the claim after 3 months of the claim.  Hence the opposite parties duty bound to pay the balance claim of the complainant. Further submitted that the opposite parties have not followed the law while issuing the policy.  The opposite parties are duty bound to issue the policy as specified by the law.  The non-issuance of policy as per law amounts to deficiency of service by the opposite parties.  It is submitted that the opposite parties have not served the terms and conditions under the Mediclaim Inurance policy.The cause of action arose for the complainant on 31.03.2013 when the complainant was discharged from the Hospital at Puttur and on 19.07.2013 when the part of the claim was paid by the 2^nd opposite party which is within the jurisdiction of this Forum.

III.      Further, on observation by us of the order sheet maintained in the case by this Forum, the necessary notice sent to the opposite party by RPAD with copies of the complainant.  The opposite party No.2 not appeared nor represented.  Hence opposite party No.2 placed ex parte.  The opposite party No.1 appeared through their counsel and filed separate version.  The opposite party stated that the complainant had obtained a policy under the Hospitalization Benefit Scheme for himself and his family members which was renewed from time to time and the last renewal was for the period 17.12.2012 to 16.12.2013.  It was based on the proposal and declaration dated 16.12.2012 by the complainant.  At that time all the terms and conditions under which the proposal had been accepted was made know to the complainant.  The policy has been issued only after the complainant satisfied himself with the terms and conditions.

It is stated that the complainant had put a claim for Rs.38,455/ on behalf of the treatment of illness of the complainant s wife Smt. Poornima s. Aithal.  The illness was diagnosed as Vault Prolapse for treatment of which the beneficiary was admitted on 23.3.2013 and discharged on 31.03.2013 at Dhanvanthari Hospital. 

The claim contained sums not covered by the policy which are as follows:

1. Rs.      70/ Registration charges.
2. Rs.    120/ Establishment charges.
3. Rs.    500/ Monitor charges.
4.  Rs.   500/ Cautery charges.
5. Rs.    100/ pulse oximeter charges.
6. Rs.    145/ URO bags and electrodes charges.
7. Rs.11,900/ bills not attaced                                                                                                                                                                       Rs. 13,335/

    The claim as mentioned above included Rs.11,900/ said to be for hospital bills.  The bills had not been attached to the claim and therefore the aggregated of all the above which were not submitted in spite of several reminders and seeking certain clarifications regarding bills were sought for by the 2^nd opposite party were not furnished by the complainant.  Therefore an aggregate amount of Rs. 13,335/ was deducted from the claim and balance amount of Rs. 25,120/ was paid.  The 2^nd opposite party explained this to the Advocate of the complainant by a letter dated 21.4.2014. And posted the case for complainant’s evidence.  Then that on 17.06.2014 complainant got examined by way of affidavit evidence and got marked the documents Ex C1 to C8.  And prays for its allow.  Arguments of the both parties also heard.Among the same of pleading with documentary and oral evidence we come to a point of proving the aspect regarding materials required by the complainant s.  As such, the point regarding.

IV.    In view of the above said facts, the points now that arise for our consideration in this case are as under:

1. Whether the complainant proves that  there is a deficiency  of service on the part of the Opposite Parties ?
2. If so, for what relief and from whom the complainant entitled?
3. What order? 

We have considered the notes/oral arguments submitted by the learned counsel and also considered the materials that was placed before this Forum and answer the points are as follows:.

Point No. (i):  As per Affirmative

Point No. (ii):  As per Affirmative

Point No. (iii): As per the final order.

REASONS

V. POINT No. (i) : The above complainant for claiming difference of part amount under the mediclaim policy with the opposite parties.  Regarding the complainant averments and claim made therein, stating that the annexed mediclaim Joint policy of the complainant and his wife and for his daughter for the period from 17.12.2012 to 16.12.2013 and also the same is renewed from year to year from 2002, by paying a premium amount of a total sum of Rs.3,170/ under the opposite party No.1, inturn the opposite party No.1 appeared through counsel and filed its detailed version, by denial of the claim made in the complainant and hence prays for its dismissal.  Wherein as on 06.5.2014, the opposite party No.2 placed as ex parte. Later, the opposite party No.1 only contested the case and it was admittedall the averments of the complaint and so also the said mediclaim policy, since the same is of renewed from year to year, from 2002 onwards and hospital treatment etc., except as show in para No.04 of its detail version dated 20.05.2014 they are denied for payment of Rs.13,335/ on different heads, and by admission they already paid only a sum of Rs.25,120/.  Hence this is the case for claiming the said difference of amount of only Rs.13,335/. Later, the complainant addressed evidence by filing his affidavit and also documents got marked as Ex C1 to C8, and closed his side. Later, opposite party No.1 neither addressed any evidence nor produced any documents, during the relevant period of time.  For the same reason this Forum also granted sufficient time for them.  Later, the matter proceeded for arguments from dated 02.12.2014.  As such that on 13.01.2015 and 03.02.2015, both the complainant and opposite party No.01 filed their written arguments respectively, contending the same by reiterated by both in the case.  In totality it is incurred a hospital expenses for surgical treatment, drugs etc is Rs. 38,555/ as mentioned below as per Ex C3, eight documents, M/s Dhanvanthari Hospital Puttur.

Date                              

22.03.2013                    Receipt           Rs.      100/

22.03.2013                     Receipt         Rs.       220/

05.04.2013                  Receipt            Rs.  12,000/

05.04.2013                Receipt              Rs.    9,910/

05.04.2013                Receipt              Rs.    1,000/

05.04.2013                 Receipt             Rs.    4,000/

05.04.2013                 Receipt             Rs.  10,625/

23.03.2013                Receipt             Rs.      700/

                                    Total              Rs. 38,555/

          So that even if the above details discloses that it is towards total medical expenses incurred by the complainant towards his wife Smt. K. Poornima S Aithal in M/s Dhanwantri Hospital Puttur during her hospitalization regarding treatment of surgery, drug, hospital etc.  So that the Opposite party No.1 admits all the aspects, despite paid only a sum of Rs. 25,120/.  Hence, for the balance of a sum of Rs.13,435/is under dispute of the opposite party No.1, as it is not ready to pay, on the ground that it not caused under the said admitted mediclaim policy, despite no terms and conditions of the policy was served on the complainant.  If ready it is so, mere on the basis of its pleadings in the version and written arguments could not be having any legal sanctity, in order to believe the entire case of the opposite party No.1.  Because in total there in no any either oral or documentary evidence addressed by its side, to prove the case, much less opposite party No. 2 in already placed ex parte.  That apart, the version of opposite party No. 1 para 5, last sentence is clearly goes to show that there was a letter dated 21.04.2014 by the opposite party No.2, addressed to an advocate of the complainant.  But in the case, no such documents before us.  As that ground itself the opposite party No. 1 utterly fails in establish its case.  Therefore we hold that the complainant process his case in all angle and also the opposite party No 1 admits the liability to that extent.  Hence, we hold that the point No.1 is in the affirmative

 POINT NO. ii:  the point No.2 is concerned the complainant is entitled for entire balance of amount of Rs.13,435/ from the opposite parties together with the interest at the rate of 10% Per annum from 31.03.2013 till make Payment.  Since it is case of a pure deficiency of service for the reasons stated above to the complainant, the opposite party is also liable to pay the adequate compensation for causing harassment for these long years, so a sum of Rs.10,000/ reasonably.   Further a sum of Rs.5,000/  also to pay towards cost and litigation charges of their case, hence for all the complainant is entitled.  Hence this point 2 is also held in the affirmative to this extent.   

POINTS No. (iii): In the result, as per the final order below:

ORDER                       

        The Complaint is allowed in part.  The Opposite parties are liable to pay jointly and severally for a sum of Rs.13,435/ (Rupees Thirteen thousand Four hundred and Thirty Five only) with interest at 10% from 31.03.2013 till realisation.  Further opposite parties are also liable to pay Rs.10,000/ (Rupees Ten thousand only) towards compensation and Rs.5,000/(Rupees Five thousand only) towards cost and litigation expenses incurred by the complainant.  Hence the Payment shall be made within 30 days from the date of receipt of copy of this order.

Copy of this order as per statutory requirements, be forwarded to the parties and therefore the file shall be consigned to record room. 

(1 to 10 pages dictated to the Stenographer typed by her, revised and pronounced in the open court on this the 04^th day of October 2016)

           MEMBER                                                        PRESIDENT                

  (SMT. LAVANYA M.RAI)                             (SMT. C. V. SHOBHA)         

D.K. District Consumer Forum                    D.K. District Consumer Forum

            Mangalore.                                                   Mangalore.      

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW 1: Mr. K. Sadananda Aithal

Documents marked on behalf of the Complainant:

Ex-C1: Dated: 16.12.2013        Copy of the policy

Ex-C2: Dated: 31.03.2013        Copy of the discharged summary

Ex-C3: Dated: 22.03.2013,

                     05.04.2013,

                     23.03.2013         Copies of the bills (8)

Ex-C4: Dated: 19.07.2013         Copy of the discharge voucher issued by  2^nd opposite party

Ex-C5: Dated: 13.12.2012         Receipt bill

Ex-C6: Dated: 23.08.2013         Office copy of the regd. Lawyer s Notice.

Ex-C7: Dated: 26.08.2013         Postal Acknowledgement of 1^st Opposite party

Ex-C8: Dated: 24.08.2013          Postal Acknowledgement of 2^nd Opposite party.

Witnesses examined on behalf of the Opposite Parties:

Nil

Documents marked on behalf of the Opposite Parties:   

Nil

Dated: 04.10.2016.                                    PRESIDENT