BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE

Dated this the 19^th JUNE 2017

PRESENT

   SRI VISHWESHWARA BHAT D     : HON’BLE PRESIDENT

SMT.LAVANYA M. RAI                 : HON’BLE MEMBER

ORDERS IN

C.C.No.341/2015

(Admitted on 10.09.2015)

Mrs. Sowmya Y Rai,

Aged about 27 years,

W/o Yatish Kumar Rai,

D/o Chandrashekhar Shetty,

A.4, 212, Simla Complex, Sheetal Nagar,

Mira Road Thane, Maharashtra  401107.

                                                                           ….. COMPLAINANT 

(Advocate for the Complainant: Sri ANN)

VERSUS

1.  Vidal Health TPA Pvt Ltd,

     413.422, 4^th Floor, Chintamani Plaza,

     Mohan Studio Compound,

Chakala, Andheri Kurla Road,

     Andheri East, Mumbai  400099.

     Represented by its Authorized Signatory.

2. The Divisional Manager,

    United India Insurance Co. Ltd,

    D.O.5, Canbatta Building, 42, M.K. Road,

    Above Eros Theatre, Mumbai  400020.

3. The Divisional Manager,

    United India Insurance Co. Ltd,

    Ram Bhavan Complex, Kodialbail,

    Mangalore  575003.

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

(Opposite Party No.1: Ex parte)

(Advocate for the Opposite Parties No.2 & No.3: Sri AKK)

ORDER DELIVERED BY HON’BLE PRESIDENT

SRI VISHWESHWARA BHAT D:

     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 her father obtained health insurance policy from opposite party No.1 from 19.08.2009 to 18.08.2010 renewed till February 2013. Oncomplainant smarriage with the Mr. Yatish Kumar Rai he settled in Mumbai and her husband has availed SyndArogya Group Mediclaim Policy from opposite party No.2 valid from 03.02.2013 to 02.02.2014 and renewed from 25.02.2014 to 24.02.2015.  She was admitted to SCS Hospital, Mangalore as an impatient was very much necessary to undergo LSCS under spinal anaesthesiaand was dischargedon 14.10.2014.  When claim was laid with opposite parties reply was not given and without any reasons & groundsrejected.  Hence contending opposite parties have failed to settle the claim even after 6 months.  Hence seeks the reliefclaimedin the complaint.

2.     Opposite party No.2 and No.3 in the versionmention denying the policy purchased by complainant’s father as claimed and admitting the policies obtained by her husbandYatish Kumar Rai as the claim is of maternitywhen has 9 months waiting period, continuity in the policy required as per terms and conditionsof the policy issued.  Thecomplainant has failed to comply with the request letter dated 04.10.2014 and 07.10.2014 in view of the breakage in the policycoverage of 22 days the claim of the complainant is not justified. Inspite of this TPA of opposite parties paid a sum of Rs.10,000/ which is 5% of sum insuredof Rs.2,00,000 to make maternity benefitunder the policy and seeks dismissal of the complaint.

3.     In support of the above complaint Mrs. Soumya Y Rai filed affidavit evidence as CW1 and answered to the interrogatories served on her and produced documents got marked at Ex.C1 to C5 as detailed in the annexure here below.  On behalf of the opposite parties Mr. Pundalik M Nayak (RW1) Divisional Manager, United India Insurance Co, Ltd, alsonot filed affidavit evidence and answered to the interrogatories served on him and produced documents got marked at Ex.R1 to R3 as detailed in the annexure here below.

4.      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.   Our findings on the points are as under follows:

               Point No. (i)  : Affirmative

               Point No. (ii) : Negative

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

REASONS

5.        POINT NO. (i):The complainantas claimed policyobtainedby her father covering the risk of life till February2013 and thereafter her husband who hadsettledin Mumbai purchased SyndArogya Group Mediclaim Policy from opposite party No.2 that complainanthusband did purchased 2 policies as claimed in complaint is not disputed by opposite parties. Theclaim of complainantfor reimbursement of medicalexpenses towards the maternity at hospital was repudiated by opposite parties as there was gap of 22 days in renewing the policy.  Hence there is alive dispute between the parties as a consumer the complainant and service provider the opposite parties  as contemplated under section 2 (1) (e) of the C P Act.  Hence we answer Point No.1 in the affirmative.

6.POINT NO. (ii):Complainant in reply affidavit to the interrogatories filed on behalf of opposite parties did admitting the SyndArogya Group Mediclaim Policyobtained from opposite party No.2 was valid from 03.02.2013 to 02.02.2014 and then from 25.02.2014 to 24.02.2015. Thus in effect admissionof gap of 22 days between the two policies.  Opposite party produced the copy of the requestlettersent to complainant to provide the insurancepolicy at Ex.R1& Ex.R2.Buteven that was not complied. Under Ex.R3opposite party intimated the complainant by rejecting the claimonthe ground as the claim in respect of the maternity which has 9 months waiting period but there was gap of 22 days.   In October 2014delivery took place has there was no policy so the claim was rejected. That complainanthas alreadymentioned did admitted there was no coverage for 22 days from 02.02.14 till 24.02.14.   The claim made by opposite party No.2 that opposite party No.1 did pay 5% of the risk covered under the policy to complainant of Rs.10,000/ is not disputed by complainants.   As such in our considered view the repudiationof the complainant is justified.  Hence we answer point No.2 in the negative.

7.POINTS No. (iii):     Wherefore 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 6 directly typed by steno on computer system to the dictation of President revised and pronounced in the open court on this the19^thJune 2017)

               MEMBER                                              PRESIDENT

      (LAVANYA M. RAI)                          (VISHWESHWARA BHAT D)

D.K. District Consumer Forum                   D.K. District Consumer Forum

             Mangalore                                                        Mangalore

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1  Mrs. Soumya Y Rai

Documents marked on behalf of the Complainant:

Ex.C1:SyndArogya Group Mediclaim Policy from opposite party No.2 vide policy bearing No.020500/48/12/14/00009233 Valid from                 03.02.2013 to 02.02.2014

Ex.C2: SyndArogya Group Mediclaim Policy from opposite party No.2 vide policy bearing No.020500/48/13/14/00011160 Valid from                 25.02.2014 to 24.02.2015

Ex.C3: Copy of Discharge Summaries (2) issued by SCS Hospital, Mangalore

Ex.C4: Copy of claim repudiation letter of opposite party dated 09.10.2014

Ex.C5: Inpatient Bills (3) issued by SCS Hospital, Manglaore

Witnesses examined on behalf of the Opposite Parties:

RW1 Mr. Pundalik M Nayak, Divisional Manager

Documents marked on behalf of the Opposite Parties:

Ex.R1: Request letter for additional information/clarification Dated 04.10.2014

Ex.R2: Request letter for additional information/clarification Dated 07.10.2014

Ex.R3: Cashless benefits rejection letter dated 09.10.2014.

Dated: 19.06.2017:                   PRESIDENT