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

Dated this the 19^th November 2016

PRESENT

SRI. VISHWESHWARA BHAT D       :  HONBLE PRESIDENT

 SRI. T.C. RAJASHEKAR                    : MEMBER

ORDER IN

C.C.No.3/2013

(Admitted on 04.01.2013)

Mr. Santhosh,

S/o V. Ramayya Shetty,

Aged about 38 years,

R/at Kamadheny Nilaya,

Meginapete House, Vittal Post,

Bantwal Taluk.

                                    ….. COMPLAINANT

(Advocate for the Complainant: SK)

VERSUS

1. The Senior Divisional Manager,

The United India Insurance Co. Ltd.,

Branch Office,

Saldhana Building, Brigade Road,

Balmatta,  Managalaore  575 001.

2. The Manager, TTK Healthcare,

Services Private Ltd, #2, HB Complex,

100 Ft BTM Ring Road,

BTM 1^st Stage, BTM Layout,

Bangalore  560 068.

                                                   …...OPPOSITE PARTIES

(Advocate for the Opposite Parties No1: AKK)

(Advocate for the Opposite Parties No.2: GVG)

ORDER DELIVERED BY HONBLE PRESIDENT

SRI. VISHWESHWARA BHAT D:

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

The brief facts of the case are as under:

     The admitted case are the complainant obtained mediclaim insurance policy mentioned in the insurance policy from opposite party No.1 covering the risk for the period from 8.7.2011 to 7.7.2012.  With history of nasal blockage on and off, discharge and head ache and other problem he was treated as im-patient from 21.5.12 to 24.5.12. He filed claim petition with opposite party No.1 as per the bill issued by hospital for Rs.37,008/.

   2.  Complainant further contends he filed claim before opposite party No.1 as per letter dated 24.5.2012.  But opposite party failed reply to the letter.  Opposite party No.2 intimated that the claim is rejected of the claim for reasons mentioned therein.  Contending

that the rejection of complainants claim as unlawful and illegal seeks payment of Rs. 2,00,000/ in all as the compensation including damages with interest at 18% and cause.

II.      Opposite party No.1 in the written version further contends it repudiated the claim under exclusion clause 4.1 of mediclaim policy.  The ailment which the complainant as undergone is not coverable of the less the policy is in 2 years continuous operation.   Hence seeks dismissal of complainant.

2.     In support of the above complainant Mr. Santhosh filed affidavit evidence as Cw1 and answered the interrogatories served on him and produced documents got marked as Ex.C1 to C6 detailed in the annexure here below.  On behalf of the opposite party Mr. Amar Kumar Sinha (Rw1) also filed affidavit evidence and answered the interrogatories served on him.

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 other reliefs claimed?
3. 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): Affirmative

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

                                                                                     REASONS

IV.      POINTS No. (i): In this case the relationship between the parties complainant as consumer having purchased mediclaim policy from opposite party No.1 and that opposite party No.1 there by the service provider and that the claim for reimbursement of medical expenses incurred by the consumers having been repudiated by op1.  Hence is consumer dispute between the parties.  Hence point no.1 answered in the affirmative.

POINTS No. (ii): In the answer furnished to the question No.2 in the interrogatories of opposite party No.1 complainant answered in the affirmative.  Question no.2 Reads thus;

2. Is it not true that you have been admitted for the treatment of sinusitis (as per the letter of Dr. H. Krishna Chandra Prasad produced by along with your complaint)

For which you have underwent septoplasty with fees as per the discharge of summary produced by you along with your complaint?

Ans:  Yes

Thus there is a clear admission by the complainant that he was treated for sinuous Ex.C5 is the discharge summary and Ex.C4 certificated issued by doctor treating complainant specifically mentioned that the complainant had nasal and sinuous problem since 6 months. 

2.      Ex.C1 the copy of the insurance policy.  But exclusion clause is found in the extract of insurance policy modified by opposite party at 4.3 that reads:

4.3: During the first two years of the operation of the policy,

The expenses on treatment of diseases such as cataract, Benign Prosthetics Hypertrophy, Hysterectomy for menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal diseases, Fistula in anus, Piles, Sinusitis and related disorders, gall bladder stone removal, gout & rheumatism, calculus diseases, joint replacement due to Degenerative condition and age-related osteoarthritis and Osteoporosis are not payable.

   3.   It is to be noted the contention raised for opponent the policy purchased by complainant is valid since 8.7.201.  There is no evidence by complainant to show that he had mediclaim insurance cover prior to 8.7.2011.  Hence we are of the view as parties to the insurance policy are governed by the contractual obligations therein the rejection of the claim by the op in view of clause 4.3 of policy is justified. Hence we answer point no.2 in the negative.

POINTS No. (iii): Wherefore the following order

ORDER

                                                                         Complaint is dismissed.

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

(Page No.1 to 6 Dictated to the Stenographer typed by her, revised and pronounced in the open court on this the 19^th November 2016)

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1  Mr. Santhosh

Documents marked on behalf of the Complainant:

Ex.C1: 2011-2012     Medi Claim Policy issued by the Opposite party No.1

Ex.C2: 19.06.2006    Medi Claim card issued in the name of complainant

Ex.C3: 22.05.2012    Rejection Letter given to the opposite  Party No.2 (2 in numbers)

Ex.C4: 24.05.2012    Certificate given by the Dr.Santhosh Kumar Shett

Ex.C5: 16.12.2011    Discharge summary issued by the  Mangala Hospital and MangalaKidney Fondation, Kadri, Mangalore

Ex.C6: 16.12.2011    Discharge Bill Receipt.

Witnesses examined on behalf of the Opposite Parties:

RW1:  Mr. Amar Kumar Sinha

Documents marked on behalf of the Opposite Parties:

Nil 

Dated:  19.11.2016                   PRESIDENT