BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE
Dated this the 17th January 2017
PRESENT
SRI VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SRI T.C. RAJASHEKAR : HON’BLE MEMBER
ORDERS IN
C.C.No.442/2014
(Admitted on 25.11.2014)
Mr. A.C. Vinayaraj,
S/o Late K.V. Chacko,
Aged 45 years,
R/o 15.17.897,
Flat No.102,
4th Cross,
Shivabhag,
Mangalore 575002.
….. COMPLAINANT
(Advocate for the Complainant: Sri ACK)
VERSUS
1. The United India Insurance Co, Ltd,
Branch Office,
Saldana Building,
Bridge Road, Balmatta,
Mangalore.
Represented by its Manager.
2. TTK Healthcare Services Private Ltd.,
11th Floor,
Brigade towers,
139 Bridgade Road,
Bangalore 560025.
having branch office at
2nd floor, city Plaza,
Kudmal Ranga Rao Road,
Near PVS Circle,
Mangalore.
…..........OPPOSITE PARTIES
(Advocate for the Opposite Parties No.1 & No 2: Sri MVSB)
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 he has been taken family Medicare policy from the opposite party No.1 since 2004 with relevant policy purchased on 12.11.2011 valid up to 11.11.2013, all documents required were submitted to opposite party No.1 before purchase of the policy. The complainant claims his daughter Riya Vinayaraj aged about 13 years (herein referred to as child) suffered from low grade fever, neck pain & tiredness was treated at various hospitals. She was diagnosed with acute leukacmia/lymphoma infiltrating the marrow. Ultimately she was admitted to Apollo Hospital at Chennai and was inpatient from 2.9.2013 to 11.9.2013. The opposite party allowed the claim of complainant of reimbursement of medical expences after delay of 77 days by crediting Rs.3,50,000/ and disallowed some of the bills amounting Rs.1,64,786/ which is un acceptable. Complainant further contends of the claim laid by complainant that item No.57 is disallowed on the ground that the bill is not found. The complainant has produced the original bill of said medicine to opposite party No.2 which is life saving medicine. The medicine was purchased by complainant by representative of Apex Pharma situated at Delhi as suggested by the treating doctor of child of the said hospital. Subsequent purchases of the medicine were allowed by opposite party. Even though complainant had sent registered letter demanding payment of remaining amount the same was not complied.
II. Opposite party No.1 filed written version which is adopted on behalf of the opposite party No.2 even for valid reasons portion of claim is disallowed the remedy of the insured person is not to claim under C P Act. Hence the question of maintainability of the claim is to be considered under condition of 5.5. The complainant is required to furnish to the TPA with all original bills, receipts and other documents upon which the clause is based on TPA/company such additional information and assistance the TPA/company may require in dealing with the claim with this back ground, the complainant claims non production of bill was properly considered and the claim was rejected. TPA got investigated and also as found as mentioned in the letter head in which the amount was mentioned. Therefore the non acceptance of complainant’s bill is proper. Hence seeks dismissal.
2. In support of the above complainant Mr. A.C Vinayaraj filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked Ex.C1 to C7 as detailed in the annexure here below. On behalf of the opposite parties Mr. Amar Kumar Sinha (RW1) Sr. Divisional Manager, also filed affidavit evidence and answered the interrogatories served on him got marked Ex.R1 to R2 as detailed in the annexure here below.
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?
The learned counsel for opposite party filed notes of arguments but neither notes of arguments filed nor oral arguments addressed on behalf of complainant. We have considered entire case file on record including evidence tendered by the parties and notes of argument of opposite parties. Our findings on the points are as under are as follows:
Point No. (i): Affirmative
Point No. (ii): Negative
Point No. (iii): As per the final order.
REASONS
IV. POINTS No. (i): The complainant had medical coverage to himself and to his family members since 2004 and there was coverage during the period with the illness of the child was treated and opposite party No.1 paid part portion of the claim in view of the liability arising out of the obligation in the terms of the policy between parties is not in dispute. Hence there is consumer and service provider relationship between the parties. The object of the complaint is disallowing of one of the item number 57 of the bills were submitted by complainant to opposite party. The opposite party mentioned that as the original bill is not produced or the bills produced is not original one it as disallowed to that extent. In the terms of the policy it is entitled to repudiate the claim to that extent. Hence there is a live dispute between the parties is contemplated under the section 2 (1) (e) of the C P Act. Hence we answer point No.1 in the affirmative.
POINTS No.(ii): There is no dispute as to the liability of opposite party No.1 in the terms of the policy towards complainant’s claim. However the only dispute raised by complainant mainly in respect of disallowing of item No.57 of the bill presented with opposite party No.2. the copy of the bill for reimbursement claim by complainant as marked at Ex.C6 item No. 57 as shown at Ex.C6 is shown as miscellaneous charges for Rs. 1,10,115/ in the ground column pertaining to this opposite party No.2 has reason for not allowing bill as mentioned as follows “bills not found so not payable ”.
2. Opposite party produced two documents Ex.R1 is the copy of receipt issued and submitted for claim by complainant by Apex Pharma house of vaccines, New Delhi. It acknowledges receive of Rs. 1,10,000/ which cover Riya Vinayaraj A the child and is dated 06.09.2013 which admittedly is not tax invoice.
3. Ex.R2 is copy of an Investigation Report as to existence of Apex Pharma which issued receipt as per Ex.R1. The report mention there is no shop in the address given at Ex.R1. As such the claim was, according to opposite party No.1 is rejected. Considering that the opposite party based the reasoning for rejection of the claim for want of the shop at the given address at Ex.R1.
4. As seen from Para 5.5 of insurance policy produced by complainant the complainant is required to produced all the original bills to opposite party No.2. Condition No.5.5 read thus:
5.5 The Insured Person shall obtain and furnish to the TPA with all original bills, receipts and other documents upon which a claim is based and shall also give the TPA/Company such additional information and assistance as the TPA/Company may require in dealing with the claim.
On going through above it is clear the complainant has not complied with this requirement and the expenditure claimed at Sl. No. 57 is not supported by valid voucher. Hence we are of the view that the rejection of the claim on that count by opposite party is justified. Hence there is no deficiency in service on the part of opposite parties. Hence we answer point No.2 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 7 directly dictated by President to computer system to the Stenographer typed by her, revised and pronounced in the open court on this the 17th 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 Mr. A.C. Vinayaraj
Documents marked on behalf of the Complainant:
Ex.C1: Original Family Medi care Policy
Ex.C2: Xerox copy of the claim form
Ex.C3: The Covering letters dated 11.11.2013
Ex.C4: The Claim acknowledgement dated 11.11.2013
Ex.C5: The original claim application
Ex.C6: Copy of Reimbursement claim approval letter
Ex.C7: The original discharge summary of Apollo speciality Hospital, Chennai (2 in numbers)
Witnesses examined on behalf of the Opposite Parties:
RW1 Mr. Amar Kumar Sinha, Sr. Divisional Manager
Documents marked on behalf of the Opposite Parties:
Ex.R1: Attested Xerox of original letter dated 06.09.2013 Of Apex Pharma
Ex.R2: Attested Xerox of report of investigator of TPA
Dated: 17.01.2017 PRESIDENT
