BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 27th October 2016
PRESENT
SMT. C.V. SHOBHA : HONBLE PRESIDENT
SMT.LAVANYA M. RAI : HONBLE MEMBER
COMPLAINT NO.77/2013
(Admitted on 14.03.2013)
M/s. Vijaya Clinic,
Maternity and Surgical Nursing Home,
Kadri Kambla Road,
Mangalore, Represented by its partner,
Dr. Priya Ballal.
……… Complainant
(Advocate for Complainant by Sri. KSB)
VERSUS
- United India Insurance Company Ltd,
Divisional Office, P.O Box No.705,
1st Floor Rama Bhavan Complex
Kodialbail,
Mangalore 575003.
- M/s TTK Healthcare TPA (P) Ltd,
#2, HB Complex, 100 ft BTM Ring Road,
1st Stage BTM Layout
Bangalore 560068.
…. Opposite Parties
(Advocate for the Opposite Parties No.1 and 2: Sri. DRK)
ORDER DELIVERED BY HON’BLE PRESIDENT
SMT. C.V. SHOBHA
- 1. This complaint is filed under section 12 of the Consumer Protection Act alleging deficiency in service as against the opposite parties claiming certain reliefs.
2. The complainant prays for the order for reliefs directing the opposite parties to pay the sum of Rs. 18,755/ with interest of 12% p.a from 01.05.2011 i.e date of discharge till date of payment, to pay sum of Rs. 20,000/ towards litigation expenses, mental agony.
The brief facts of the case are as under:
The case of the complainant Hospital as a welfare measure has obtained Health Insurance Group Policy No. 070800/48/10/05/00002808 from opposite party No.1 for period commencing from 09.02.2011 to 08.02.2012 for the benefit of its employees and the required premium has been paid in this regard by complainant. In the matter of Sri Manjunath Shenoy (I.P.No. 480/11) holding ID card No. BLR UI.V0339.001.0000010.A under policy No.070800/48/10/05/00002808 issued by opposite party No.1, an employee of the complainant was covered under the aforesaid policy. He was admitted on 27.04.2011 with history of Swelling in both breasts and complaint of pain since 2 months. On diagnosis the same revealed that he had bilateral gynaeomastia with mastitis. He underwent excision of bilateral gynaemastia. The complainant hospital and complainant has incurred medical expenses of Rs. 18,755/. On successful completion of the treatment he was discharged from on 01.05.2011 and the Hospital charge in respect of the treatment availed by him came to Rs. 18,755/ bill dated 01.05.2011 was raised in this regard and as agreed upon in the above Insurance Policy and presuming that they would reimburse the said charges the said Manjunath Shenoy was discharged from the Hospital without him paying a single rupee. The complainant even to this date has not collected from the said Sri. Manjunath Shenoy the said treatment charges.
In respect of the above patient was sent to opposite party No.1 immediately thereafter and all the required copies of the records were furnished to opposite party No.2 as per the direction of opposite party No.1. Thereafter, for few months there was no response from both the opposite parties. The opposite party No.1 through its TPA i.e opposite party No.2 vide query dated 11.11.2011 sought further break up of the medicines and consumables details and accordingly the same were furnished. The complainant Hospital therefore issued a reminder dated 02.05.2011 to opposite party No.2 in this regard. The opposite party No.2 rejected the complainants claim vide and the same was received by the complainant on 06.06.2012. It is amusing to find that opposite party No.2 has termed the above procedure as a treatment for cosmetic reason. The said procedure was performed as the patient had pain since 2 months and had swelling in both breasts. It is surprising to find that Opposite Party No.2 has termed the above procedure as a treatment for cosmetic reason and rejected the claim vide your undated letter, received by applicant on 06.06.2012. At the time of availing the aforesaid policy it was agreed that opposite party No.1 would reimburse to the complainant the treatment medical expenses incurred by the employees of the complainant.
Hence, the applicant got issued lawyers notice dated 09.11.2012 demanding payment towards reimbursement of medical expenses i.e a sum of Rs. 18,755/ on dated 27.04.2011 to 01.05.2011 in respect of treatment availed by Sri. Manjunath Shenoy. The opposite parties have given a false and frivolous reply. Hence, the above complaint.
II. Version Notice served to the opposite party by RPAD filed version. The opposite parties admits that the complainant had obtained helath Insurance group policy No. 070800/48/10/05/00002808 from the opposite parties. The opposite parties admits that Sri Manjunath Shenoy, an employee of complainant was covered under the aforesaid policy but subject to terms and conditions of the policy issued by opposite parties. The opposite parties admits that the complainant has claimed of Rs. 18,755/ for aforesaid Sri. Manjunath Shenoy for his alleged medical expenses. But the opposite parties denied that Sri. Manjunath Shenoy has incurred medical expenses of Rs. 18,755/.
The complainant has suppressed the material facts with regard to the alleged treatment. The opposite parties have scrutinized mediclaim documents and it is observed for the hospital discharge summary that the aforesaid Manjunath Shenoy has presented history of swelling both breasts with pain since two months and diagnosed as bilateral gynaemastia with mastitis and underwent excision of bilateral gynaemastia under G.A. the said document very clearly disclosed that Sri. Manjunath Shenoy’s treatment is related to cosmetic reason. Under clause 4.6( C) of the insurance policy, it very clearly stated that change of life, or cosmetic or aesthetic treatement of any description such as correction of eyesight, is not covered under the policy. The opposite parties submits that, the opposite parties are not liable to pay to the complainant a sum of Rs. 18,755/ with interest at 12% p.a. from 01.05.2011 till the date of payment and also not liable to pay a sum of Rs. 20,000/ litigation expenses as alleged in the complaint. The complainant Mr. P.Vittal. Rao (CW1) filed evidence by way of affidavit and got marked the documents as Ex C1 to C13. On behalf of the opposite parties Amar Kumar Sinha (RW1) were examined and marked the documents as Ex R1.
III. In view of the above said facts, the points now that arise for our consideration in this case are as under:
- Whether the complainant proves that there is a deficiency of service on the part of Opposite Parties as per the complaint?
- If so, for what quantum and from whom the complainant in entitled?
- 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
iV. POINTS No. (i) and (ii):
The above complaint raised by the complainant M/s Vijaya Clinic, against opposite party 1 and 2, on the strength that there was a health insurance group policy to the said complainant hospital, which was represented by one Dr. Priya Ballal, who got the same mediclaim policy under the said health insurance as it is of a group policy, where in the same was covers to all the employees, who worked under the said Dr.Priya Ballal in the said hospital, which is running under the name and style of M/s Vijaya Clinic, maternity and surgical nursing home.
For which the complainant paid a huge sum of money towards the premium amount, for all the employees about 12 (Twelve) in numbers of a total sum of Rs. 15,814/, every year with the contract between opposite party No.1 and 2. Inturn, on receipt of the same premium amount every year the opposite party No.1 issued the policy which is as per Ex C13 and R1. Under the same, one Sri Manjunatha Shenoy who was working under the complainant hospital and he took treatment as an inpatient and under went surgical treatment. For which the complainant hospital so far incurred a total sum of Rs. 18,755/ towards all the medical expenses. Hence as per the contract, terms and conditions derived between them, now the complainant actually demanded and claimed its legal entitlement of the said amount with both the opposite parties. Despite, without any valid reasons and grands they have refused to make payment.
On the ground that the group insurance policy in question under the health insurance has been admitted for the period from 09.02.2011 to 08.02.2012, it is also for the main object for the benefits of its employees, in the course of any happening regarding treatment and expenses occurred. Accordingly, the said Manjunath Shenoy was treated in complainant, hospital on 27.04.2011 as, an indoor patient with the history of swelling in both breasts and complaint of pain since 02 months. On diagnosis the same revealed that he has bilateral gynaemastia with mastitis. He under vent excision of bilateral gynaemasti. For the reason of the same invaluable he was treated with necessary surgery. For which the complainant incurred the said medical expenses of a tune of Rs. 18,755/. And thereafter he was discharged from the hospital on 01.05.2011, due to the same the authority of the complainant was also issued a necessary cash bill dated 01.05.2011. The same is under challenge by the complainant for its reimbursement from the opposite parties concerned. Further till date no amount towards the same was collected from the said Sri. Manjunath Shenoy, by the complainant hospital.
In the result, the necessary claim made with the opposite party No.1 by producing all the necessary required documents produced even to opposite party No.2 , as per the direction of opposite party No.1. Even though no purpose was severed. Then the complainant made all the efforts for long time, thereafter i.e on 06.06.2012 the opposite party No.2 rejected the said valid claim of the complainant, mainly on the ground that the said treatment is of a cosmetic one. Hence, under the policy it was not allowed as per the opposite party so that, one legal notice dated 09.11.2012 also made by the complainant, seeking the same relief. In spite of it nothing was done, for all the facts and circumstances, the complainant prays for the appropriate relief under the said pleading, oral and documentary evidence, written arguments made in the case. On the other hand the opposite party straight away prayers for its dismissal. Now, the points for consideration is derived under the medical record which produced by the complainant under Ex 14 containing 09 sheets of Sri. Manjunath Shenoy, admission No. 480/2011, who treated by Dr. Jayaram Shenoy , from 27.04.2011 to 01.05.2011. The said document containing admission and discharge records, surgery records and other reports available for our consideration. If reveals the said surgical treatment given to him as already stated above. Despite, the opposite party raised a dispute on the strength that it is of a Cosmetic treatment ? So that we also observed from the said written arguments of the complainant hospital available in the record, clearly goes to show the treatment which given by the complainant hospital to Sri. Manjunath Shenoy was not at all of a Cosmetic either reason or treatment. Because, the same is also clearly mentioned that the said Gynecomastia is the begin proliferation of glandular breast tissue in men and that surgery have a major role in treating gynecomastia in select patient and mastitis, an infection of the breast tissue, in such cases, surgery is required. As per the above facts, has been noticed from the medical literature, which also produced by the complainant. Under these circumstances we come to a conclusion that there is no any weightage, in the objection raised by the opposite party for its rejection in make payment of the same on the ground of it was of a cosmetic reason and treatment. Therefore we considerably opined that it is not at all a cosmetic reason or treatment. Hence the said claim which made by the complainant against the opposite party for reimbursement of the said entire sum of 18,755/ as per Ex C1 is of a legal demand and claim. So, on any ground, any of the opposite party cannot escape from make payment in full. If so, the same is denied by the opposite party o the ground of causing loss and damage to the complainant, with a malafide intention in order to have a wrongful gain. Under that ground alone it is a clear case that, the opposite parties are in a pure deficiency in service to act with the complainant. Further it also leads to the place of unfair trade practice. Because admittedly it is of a commercial business in the market by collecting a huge sum of money towards the premium, and in turn just to issue the said policy. Further, the need of having the same by the complainant with the opposite party, is also far just to indemnify, as per the contract of indemnity. So that, the said main object of the same was totally ignored by both the opposite parties. Hence the complainant causing, suffering, pain, mental agony as well as economic loss and damage. Hence, we conclude that for the reasons stated above by us with all the discussions made we hold that the said both the points are in the affirmative.
Hence, we direct both the opposite parties are jointly and severally liable to pay the said sum of Rs. 18,755/ in fall with the accused interest on the said sum at the rate of 10% p.a computing from 01.05.2011 till make payment.
Further, even towards causing harassment, mental agony etc the opposite parties are also liable to pay a sum of Rs. 5,000/ towards the compensation together with another sum of Rs. 3,000/- towards cost of litigation charges incurred by the complainant so far. Accordingly, for all the award made above by us to the complainant, as it is entitled.
POINT No. (iii): In the result, as per the Order below:
ORDER
Complaint is allowed in part. All the opposite parties are responsible and liable to pay for a sum of Rs.18,755/ (Rupees Eighteen thousand Seven hundred Fifty Five only) with accrued interest at 10% p.a. from 01-05-2011 till make payment. Further, the opposite parties are also liable to pay a sum of Rs.5,000/ (Rupees Five thousand only) towards compensation and another sum of Rs.3,000/ (Rupees Three thousand only) towards cost and litigation expenses incurred by the complainant. Payment shall be made with In 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 him, revised and pronounced in the open court on this the 27th 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. P.Vittal. Rao
Documents marked on behalf of the Complainant:
Ex.C1: 01.05.2011 Bill issued by the complainant to O.P No.1 through O.P No.2 with endorsement.
Ex.C2: 25.08.2011 Letter issued by complainant to O.P No.1
Ex.C3: 11.11.2011 Intimation seeking details issued by O.P No2.
Ex.C4: 02.05.2012 Reminder issued to O.P. No.2.
Ex.C5: 24.05.2012 Email sent by O.P No.2 to complainant.
Ex.C6: 06.06.2012 Rejection of Claim by O.P.No.2.
Ex.C7: 08.06.2012 Letter issued by Complainant to O.P.No.1.
Ex.C8: 09.11.2012 Lawyer s Notice issued on behalf of complainant to O.P s With acknowledgments (2in No s).
Ex.C9: 27.10.2012 Lawyer s reply by O.P.No.1.
Ex.C10: 01.05.2011 C/o Discharge summary of Manjunath Shenoy.
Ex.C11: 01.05.2011 Receipt issued by Dr. T.V Shenoy for having received Professional charges in respect of the above patient.
Ex.C12: 01.05.2011 Receipt issued by Dr. Jayaram Shenoy for having Received professional charges in respect of the above Patient.
Ex.C13: C/o Policy Schedule.
Witnesses examined on behalf of the Opposite Parties:
RW.1: Amar Kumar Sinha
Documents produced on behalf of the Opposite Parties:
Ex.R1: Policy copy.
Dated: 27-10-2016 PRESIDENT
