BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE                        

Dated this the 12^th April 2017

PRESENT

   SRI VISHWESHWARA BHAT D     : HON’BLE PRESIDENT

   SRI T.C. RAJASHEKAR                 : HON’BLE MEMBER

ORDERS IN

C.C.No.108/2014

(Admitted on 27.03.2014)

P.S. Sukhanya Rai,

D/o B.S. Vittal Rai,

Aged about 26 years,

R/at Bolikala House,

Madavu Post, Keyyur village,

Puttur Taluk, D.K.

                                                                      ….. COMPLAINANT

(Advocate for the Complainant: Sri SD)

VERSUS

1. The Manager,

National Insurance Co.Ltd,

1^st Floor Dharmasthala Building 

Main Road, Puttur, D.K.

2. Manager,

Dedicated Health Care Services,

TPA India Pvt. Ltd,

502, Brigade Tower, 135 Brigade,

Bangalore 35.

                                                                   ….......OPPOSITE PARTIES

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

(Opposite Party No.2: Ex parte)

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.7,820/ to the complainant with 12% interest from 20.9.2013 till payment, to pay Rs.20,000/ towards compensation, to pay Rs.10,000/ towards expenses and such other reliefs.  

2.      In support of the above complainant P.S.Sukhanya Rai, filed affidavit evidence as CW1 and answered the interrogatories served on her and produced documents got marked at Ex.C1 to C11 as detailed in the annexure here below.   On behalf of the opposite parties M. Subramanya Kini, (RW1) Assistant Divisional Manager, National Insurance Company Limited, also filed affidavit evidence and answered the interrogatories served on him and produced documents got marked at Ex.R1 as detailed in the annexure here below. 

The brief facts of the case are as under:

We have perused the complaint and the version of the parties. This dispute is with regard to the medical bill spent on delivery is not refunded by the opposite parties in spite of insurance coverage of Rs 30000/. The complainant alleges that she is, along with other 3 family members holder of universal health insurance policy from the opposite party No 1. The complaint admitted to hospital for delivery and spent Rs 10320/ and sent the bills with required documents for reimbursement. The opposite party have settled the claim for Rs 2500/ only. Hence alleges deficiency in service. The opposite party No 1 not filed his version but through interrogatories and produced documents established  that, the maximum amount eligible for delivery expense is only Rs 2500/ and the same has been paid and there is no deficiency in service on the part of the opposite parties. These are being the facts of dispute we consider the following

POINTS FOR ADJUDICATION

          On perusal of the complaint and the evidence led the admitted facts are, the issue of the health insurance policy and the complainant is one of the beneficiary. The policy is issued in the name of the complainants father.  It is admitted that the complainant admitted to hospital for delivery and had submitted the claim form, and the opposite parties have considered only Rs 2500/ as admissible claim and the same has been paid and received. It is denied that the opposite parties have issued the policy conditions with the insurance policy. The opposite party denies that the complainant is the policy holder but only beneficiary. On reconciliation of admissions and the denials we consider the following points for adjudication.

1. Whether the complainant is a consumer under the consumer protection Act 1986?
2. Whether the complainant proves the deficiency in service on the part of the opposite parties?
3. Whether complainant entitled for the relief prayed for?
4. What order?

We have considered the evidence lead by the parties and documents produced on record. Heard the party submissions and answered the above points as under.

1. In the affirmative.
2. In the negative.
3. In the negative.
4. As per delivered order.

REASON

POINT NO 1: The complainant produced the policy copy as EX C 1has the name of the complainant as beneficiary and the insurance policy issued in the name of Mr B.S.VITTAL RAI who is said to be the father of the complainant. Even though the father paid the premium and the contractual obligation is in between the father of the complainant and the opposite parties, the father paid the premium for the benefit of the complainant and as such the complainant is the consumer and the opposite parties are the service provider. Hence we answered the point no 1 in the affirmative.

POINT NO 2 & 3: The complainants dispute is the opposite parties are bound to settle the claim of delivery expenses of Rs 10320/ as the sum assured is Rs 30000/ for family. The complainant produced the one sheet of the policy copy and stated that he has received only one page of the policy and he has not supplied with the terms and conditions of the policy and hence the opposite party has no right to deduct any amount from the claim made. However, the opposite party No 1 has produced the terms and condition of the policy. On observation of the policy it was found that the normal delivery expenses are limited to Rs 2500/ as liability of the insurer. The question is whether this condition was known to the complaint or not?

          As per complainant allegation the opposite parties have not supplied the terms of the policy. It is pertinent to note that the policy is issued in the name of the father of the complainant and it is elicited from the interrogatories (Q NO 4 to 6) that, the proposal form is also filled up by the father of the complainant. In this situation we are unable to go with the contention of the complainant being beneficiary only that, the opposite party has not provided with the copy of the terms and conditions. The father of the complainant is not a party to this complaint. It is also revealed from the interrogatories(Q NO 3) that the present policy is not of first year but it is a renewed policy and supplying of terms and condition in normal course sometimes dispensed with in the renewed policies. Hence the opposite parties have settled the claim as per policy condition and we see no deficiency in service on the part of the opposite parties. Hence we answered the point no 2 in the negative and point no 3 also in the negative.

POINT NO 4: In the light of the above discussion and the adjudication of the points we delivery the following

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 5 directly typed by Member, revised and pronounced in the open court on this the 12^th April 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  P.S.Sukhanya Rai

Documents marked on behalf of the Complainant:

Ex.C1: 26.3.2013: Copy of the card with policy.

Ex.C2: 5.9.2013: Copy of the claim form.

Ex.C3: 20.9.2013: Copy of the discharge summary.

Ex.C4: 20.9.2013: Copies of the bills (7).

Ex.C5: 6.12.2013: O/c of the regd lawyers notice.        

Ex.C6: 9.12.2013: Postal acknowledgments of Opposite Parties (2)

Ex.C7: 15.1.2014: O/c of the regd lawyers notice.

Ex.C8: 4.12.2013: Copy of the discharge voucher.

Ex.C9: 16.1.2014: Postal acknowledgement of 1^st Opposite Party.

Ex.C10: 22.1.2014: Copy of the pass book of Canara Bank.

Ex.C11: 21.1.2014: Reply of 2^nd Opposite Party.

Witnesses examined on behalf of the Opposite Parties:

RW1  Subramanya Kini, Assistant Divisional Manager, National Insurance Company Limited,

Documents marked on behalf of the Opposite Parties:

Ex.R1: copy of the universal health insurance policy with schedules of premium for the years 19.3.2011 to 18.3.2012 and from

          26.3.2013 to 25.3.2014 issued to B.S.Vittal Rai father of the  complainant.

Dated: 12.4.2017                                          MEMBER