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

Dated this the 6^th April 2017

PRESENT

   SRI VISHWESHWARA BHAT D     : HON’BLE PRESIDENT

   SRI T.C. RAJASHEKAR                  : HON’BLE MEMBER

ORDERS IN

C.C.No.182/2014

(Admitted on 21.05.2014)

Mrs. Ambalika Suhel,

Wife of Suhel Samad,

Aged  years,

R/o 603, 6^th Floor,

Thumbey Plaza, Alape Padil,

Mangalore.

                                                                    ….. COMPLAINANT

(Advocate for the Complainant: Sri NKS)

VERSUS

1. The Reliance Life Insurance Company Ltd,

    Registered Office, H Block,

    1^st Floor, Dhirubhai Ambani knowledge city,

    Navi Mumbai,

    Maharastra  400 710,

    Represented by its authorized signatory.

2. Medi Assist India TPA Pvt Ltd,

    II Floor, 45/A, 1^st Main Road,

    Sarakki Industrial Layout,

    J.P. Nagar Phase III, Bangalore 560 078,

    Represented by its authorized signatory.

3. The Manager,

    The Reliance Life Insurance Company Ltd,

    3^rd Floor, Maximus Commercial Complex,

    Light House Hill Road, Hampankatta,

    Mangalore  575 001.

                                                                         …...........OPPOSITE PARTIES

(Advocate for the Opposite Parties No.1 & No.3: Sri SPDS)

(Opposite Party No.3: Exparte)

ORDER DELIVERED BY HON’BLE PRESIDENT

SRI. VISHWESHWARA BHAT D:

I.       1. The above complaint filed under Section 12 of the Consumer Protection Act by the complainant against opposite parties alleging deficiency in service claiming certain reliefs. 

The brief facts of the case are as under:

     The complainant claims she obtained a life insurance policy from opposite party Reliance Care for You Plan on 29.9.2013 by paying a premium of Rs.12,149.53 making promises. Complainants’ husband was admitted to Yenopoya Hospital on 6.11.2013 due to high fever and other complication and was treated and discharged on 9.11.2013.  The test for dengue showed negative report.  When the bills were submitted of the expense of Rs.7,855/ incurred by the hospitalization repudiated the claims even after legal notice hence seeks the relief claimed in the complaint.

II.    Opposite parties No.1 and No.3 filed version the deficiency in service is not shown by the complainant, on that count itself the complaint is not maintainable.  The complainant obtained Reliance Care for You Plan issued on  30^th September 2011 premium paying term 3 years and the policy term 3 years with policy commencement date on 29.9.2011 and sum issued Rs.2,00,000/ with yearly premium payment at 11,015/.  The complainant was admitted at Unity Health Complex Hospital on 6.11.2013 for 4 days for fever with chills, headache and generalised weakness.  The temperature of complainant on admission was 100 degrees Fahrenheit, Pr.80bpm, BP 100/90mmHG and incurred expense of Rs.7,855/ for treatment.   The health condition of the complainant did not warranted for hospitalisation and the treatment could have been managed on out patient basis.   Hence the claim was rejected.  In view of clause 6.4 and 1.1.9 the opposite parties is not liable to pay to reimburse the assessment.  Hence seeks dismissal of the complaint.

2.     In support of the above complainant Mrs. Ambalika Suhel filed affidavit evidence as CW1 and answered the interrogatories served on her and produced documents got marked at Ex.C1 to C7 as detailed in the annexure here below.  On behalf of the opposite parties Mr. Deeraj B. Udyawar (RW1) Area Manager of Reliance Life Insurance Company Ltd, also filed affidavit evidence and answered the interrogatories served on him and produced documents got marked at Ex.R1 to R5 as detailed in the annexure here below. 

III.    In view of the above said facts, the points for consideration in the case are:

1. Whether the Complainant is a consumer and the dispute between the parties?
2. If so, whether the Complainant is entitled for any of the reliefs claimed?
3. What order?

      The learned counsels for both sides filed notes of argument.     We have considered entire case file on record including evidence tendered by the parties and notes of argument of the party.  Our findings on the points are as under are as follows

               Point No.  (i): Affirmative

              Point No.  (ii): Affirmative

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

REASONS

IV.   POINTS No. (i):     Complainant  purchased the life policy from opposite party is undisputed.   Hence relationship of consumer and service provider is established.  The complainants claims for reimbursement of the medical expenses towards hospitalization of her husband was repudiated by opposite party.  Hence there is live dispute between the parties as contemplated under section 2 (1) (e) of the C P Act.  Hence we answer Point No.1 in the Affirmative.

POINTS No. (ii):   The only point for consideration is whether the policy condition exclusion permits opposite parties to repudiate the claim.  In the written version opposite parties went on mentioning that complainant had taken treatment when it is specific case of complainant the hospitalization and treatment was taken by her husband Suhel Samad.   As seen from the policy as per the claim it is not a case of opposite party that the husband of complainant is not covered under the policy.  Proposal form mentions the name of the complainant, husband and the children.

 2.     Ex. C2 is the discharge bill of the Suhel Samad issued by Unity Health Complex Hospital.   Nowhere in this document there is mention made of nature of illness but it records the microbiology lab test for Dengue igG & igM (SPOT) Test and other Biochemistry, Hematology test done.  Ex.R5 is a certificate issued by Unity Health Complex in respect of Suhel Samad hospitalization mention the patient had 100 degrees Fahrenheit, Pr.80bpm, BP 100/90mmHG and he was investigated for Malaria, Dengue & other infections caused and all tests were negative.   It also mentions he was treated on outpatient basis on 4.11.2013 at Yenopoya nursing home and treated there is no improvement in symptoms and so patient got admitted.   It also recorded during the stay in hospital he had vomiting and was treated with IV fluid & IV PPI IV Antibiotic, IV PPI, IV Fluid cannot be given on op basis.   Thus on going through relevant portion at Ex.R5 it is clear the patient could not have been treated as outpatient due to the symptoms experienced by him.  

3.     Ex.R2 is the copy of the policy issued to complainant clause 6.4 reads the clause 6 is about exclusion & clause 6.4 reads thus:

6: Exclusion: Unless expressly stated to the contrary we shall not be liable to make any payment for any claim in respect of any Insured Person when that claim is directly or indirectly caused by; arises from or is any way attributable to any of the following:

 6.4: Expenses where are not for actual, necessary and reasonable expenses incurred in the treatment of the illness or physical injury or any elective surgery or treatment which is not medically necessary.

Again clause 1.1.9 of the policy reads thus:

1.1.9 Day Care Treatment or Procedure means the course of medical treatment of surgical procedure carried out in Hospitals or in specialized day care centres which are fully equipped with advanced technology and specialized infrastructure.  The procedure must require Hospitalization for less than 24 hours and must be on written advice of Medical Practitioner.  The Eligible Medical Expenses to be reimbursed under this benefit shall consist of cost of Day Care Treatment for listed Day Care Procedures as given in Annexure 1.  The company reserves the right to modify the list of Day Care Procedures from time to time, subject to the Regulator’s approval and the Policyholder shall be informed of the same. However, treatment normally taken on an outpatient basis including procedures carried out in General Practice clinics, is not included in the scope of this definition.

As seen for the annexure to the policy on day care procedures we are unable to point on which specific point the opposite party intends to bring complainant case or for his exclusion.  Suffice to mention that from the document Ex.R5 produced by opposite party mention made therein by the consultant physician Dr. Muneer Ahmed that:

Even though patient was diagnosed to have viral fever it cannot be treated on op basis when patient having multiple symptoms & which require IV line of treatment.  

4.     As to the claim of opposite party as to day treatment procedure under clause 1.1.9 is concerned the form the document produced by opposite party Ex.R5 itself hospitalization was essential in the case of the complainant.  Hence for restriction contemplated in 1.1.9 is not applicable to the facts on hand.

5.     Hence we are of the view the claims for opposite party as the complainant have taken treatment as outpatient and the hospitalization is not called off by opposite parties is not accept.

6.     Learned counsel for opposite party referred to the cases of reported cases namely Kishore Chandrakant Rathod vs. Managing Director, ICICI Prudential Life Insurance Co Ltd and Ors, under Revision Petition No.3390/2013 of NCDRC, Life Insurance Corporation of India & Ors. vs. Smt. Asha Goe & Anr. 2001 SCC 160 and Export Credit Gurarantee Corpn. Of India Ltd vs. Garg sons International 2013 (1) Scale 410.   However ongoing through the reported case laws as quoted by the learned counsel in the written argument and the facts of the case on hand the law laid down in the reported case laws are not applicable to the case on hand.

7.     Hence we are of the view repudiation made on the part of opposite party amounts to deficiency in service.  Hence we answer point No.2 in the affirmative.

POINTS No. (iii): The complainants claim is based on the medical bills marked at Ex.C2 is the copy of the medical bill it shows amount paid at Rs.7,855/- at the hospital towards hospitalization and medications which is the amount claimed by the complainant towards expenses shall be awarded against opposite party.  Apartment from this towards hardship, mental agony, financial loss, stress and strains an amount of Rs.10,000 in the circumstance in our opinion is just and proper.  An amount of Rs.5,000/- towards advocate fee is just and proper.  Wherefore the following order

ORDER

     The complaint is allowed with cost.  Opposite party is directed to pay Rs.7,855/ (Rupees Seven thousand Eight hundred Fifty Five only) to complainant with future interest at the rate of 9% per annum from the date of complaint till the date of payment.

2.  Opposite party is also directed to pay a sum of Rs.10,000/ (Rupee Ten thousand only) as compensation to complainant.

3.    Advocate fee fixed at Rs.5,000/- (Rupees Five thousand only).

4. The above amounts shall be paid 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 free of cost and file shall be consigned to record room.

     (Page No.1 to 9 directly typed by steno on computer system to the dictation of President revised and pronounced in the open court on this the 06^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  Mrs. Ambalika Suhel

Documents marked on behalf of the Complainant:

Ex.C1: Notarised copy of Reliance Care for You Plan Insurance Policy  

Ex.C2: Xerox medical bills (originals already submitted to the OP)

Ex.C3: Claim Form

Ex.C4: Dated 30.01.2014 Copy of legal notice

Ex.C5,

Ex.C6 &C7: Acknowledgement cards                   

 Witnesses examined on behalf of the Opposite Parties:

RW1  Mr. Deeraj B. Udyawar, Area Manager of Reliance Life Insurance Company Ltd,

Documents marked on behalf of the Opposite Parties:

Ex.R1: Copy of proposal form

Ex.R2: Policy Document

Ex.R3: 12.11.2013 copy of day care procedure benefit Claim Form

Ex.R4: 26.11.2013 copy of rejection letter

Ex.R5: Copy of medical certificate issued by Unity Health Complex

Dated: 06.04.2017                                     PRESIDENT