Date of Filing:18.10.2008<br /> Date of Order:13.02.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> Dated: 13TH DAY OF FEBRUARY 2009<br /> PRESENT<br /> <br /> <br /> <br /> Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> <br /> <br /> COMPLAINT NO: 2246 OF 2008<br /> <br /> <br /> Subhasis Bandyopadhy<br /> Employee ID-16255 of Oracle Financial <br /> Services Software Ltd., (was formerly iflex solutions Ltd)<br /> Platinum City, Flat No.G/4/10, 4th Floor, <br /> HMT Road, Tumkur Highway, Peenya,<br /> Yeshwanthpur, Bangalore 560 022. Complainant<br /> <br /> <br /> V/S<br /> <br /> 1. Claims Department,<br /> United Health Care,<br /> # 1, Victor Manson, Golf View Avenue,<br /> Airport Road, Kodihalli, Bangalore-08.<br /> <br /> 2. Authorized Signatory,<br /> ICICI Lombard GIC Limited,<br /> Health Claim Operations,<br /> Interface Building No.11, 401, 4th Floor,<br /> Malad Link Road, <br /> Behind Goregon Sports Club,<br /> Malad (W), Mumbai-400064. Opposite Parties<br /> <br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a complaint filed by the complainant. <br /> The brief facts of the case are that, the complainant company Oracle Financial Services Software Ltd., is having group medical insurance with opposite party No.1 and opposite party No.1 in turn is associated with ICICI Lombard General Insurance Company Ltd.,. Complainant’s mother Deepa Banerjee was admitted to National Institute of Mental and Neuro Science on 4th December-2007 for treatment. Dr. Panda examined her and suggested certain tests. As per the Doctor advice entire test was conducted. Report was submitted on 14th December-2007. Seeing the report Doctor predicted that the patient may be suffering from sensory motor polyneuropathy or vasculitic neuropathy. Doctor advised to admit the patient to the hospital. Complainant’s mother got admitted in Nimhans on 14th December-2007. She stayed in the hospital for 18 days and reputed panel of Doctors made several diagnosis and treatment. The Doctors come to conclusion that patient is suffering from sensory motor polyneuropathy. Same is depicted in the discharge certificate. She was got discharged from the hospital on 31st December-2007 with proper medical advice. The biopsy report suggested that patient is suffering from vasculitic neuropathy with reparative axonal sprouts. Complainant gathered all the relevant documents and submitted claim. He received letter from opposite party No.2 stating that claim got rejected on the ground that no active line of treatment. Hence, the complainant approached the Consumer Disputes Redressal Forum for getting justice. Complainant is a salaried person since the disease of his mother “sensory motor polyneuropathy and vasculitic neuropathy” is a very serious disease required lot of medical attention which are very expensive. Therefore, he prayed to direct the Insurance Company to pay amount of Rs.35,522/- towards hospitalisation charges. <br /> 2. Notice was issued to opposite parties. Notice was served on opposite parties. Opposite party No.1 though served with notice, not appeared before the Forum. Hence, opposite party No.1 placed exparte. Opposite party No.2 appeared through counsel and filed defense version admitting that policy was issued for the period from 24/04/2007 to 25/04/2008 (it should be 25/04/2007 to 24/04/2008). As per the terms of condition No. 4.10 of policy claim is excluded. The mother of complainant has not taken treatment for any specific disease. Hence, claim repudiated. The opposite party No.2 prayed to dismiss the complaint. <br /> 3. Complainant filed his affidavit evidence and documents. On behalf of opposite party No.2 also affidavit evidence filed. Arguments are heard.<br /> 4. The points for consideration are:- <br /> 1. Whether the repudiation of claim by the <br /> opposite party No.2 is justified?<br /> <br /> 2. Whether the complainant is entitled for the <br /> claim amount? <br /> <br /> REASONS<br /> 5. It is an admitted case of the parties that the complainant has taken Group Health Insurance Policy from the opposite party No.2. The policy covered period was from 25/04/2007 to 24/04/2008. The only ground taken by the opposite party No.2 for repudiating the claim of the complainant is that the mother of the complainant has not taken any treatment for specific disease and therefore such expenses are not payable and same is excluded under the terms and conditions of the policy. The opposite party relied upon clause 4.10 of the policy. The opposite party No.2 has also given letter to the complainant stating that they have received the paper and documents for processing the claim and they regret their inability to admit the claim and claim should be rejected as per clause 4.10 in active treatment. The complainant has produced a certificate from Physiotherapist. He has submitted his certificate that Smt. Deepa Banerjee, the mother of complainant diagnosed with sensory motor polyneuorpathy from Nimhans Hospital, Bangalore. She was undergone for physiotherapy under his supervision. The mother of the complainant Smt. Deepa Banerjee admitted in National Institute of Mental Health and Neuoro Science, Bangalore. She was admitted on 14/12/2007 and discharged on 31/12/2007. The Nimhans have given clinical history which has been produced by the complainant at Exibit-2. She has undergone several tests at Anand Diagnostic Laboratory. The clinical history sheet shows course in hospital and condition on discharge. The Doctors of Nimhans have observed as under:-<br /> “on evaluation NCS showed evidence of sensory motor polyneuropathy. MRI Brain showed Diffuse atrophy – more in cerebellum – T2 and FIAIR hyperintensity in B/L – peritrigonal area and middle cerebellar peduncle. CSF was normal. Workup for malignancy and paraproteinemia were negative. The possibility of sporadic Cerebellar degeneration with associated polyneuropathy was considered. The ophthalmoplegia was considered to be independent of the present illness. She is being discharged with advice as below.” <br /> <br /> 6. By the several documents and records of hospital, it is a Government Hospital and very famous hospital in India. The discharge report given by the Doctors of Nimhans shall have to be accepted. There is absolutely no merit in the defense of the opposite party that Smt. Deepa Banerjee has not taken active treatment for any specific disease. It cannot be said by any stretch of imagination that the mother of complainant had not taken treatment for specific disease. The exclusion clause 4.10 of policy conditions is not at all applicable to the facts of the present case. The mother of complainant was admitted to the Nimhans Hospital and she had taken treatment there she had undergone several tests. The Doctors have opined that she was suffering from sensory motor polyneuropathy. Therefore, the repudiation of claim by the opposite party is unjustified. The opposite parties should have allowed the claim and paid the amount to the complainant. Consumer Protection Act is a social and benevolent legislation, it is intended to protect the better interest of the consumers. Consumer Protection Act is a milestone in the history of legislation and is directed towards achieving public benefit. The Act attempts to remove the helplessness of the consumer which he faces against powerful business house or company. The complainant having taken Group Medical Health Policy and having spent amount towards treatment of his mother, the opposite party is bound to pay the amount and accept the claim. The complainant has claimed Rs.35,522/- in this complaint. Out of this amount he has claimed Rs.5,800/- towards physiotherapy treatment for 21 days at the rate of Rs.200/- per day. There is no receipt for this amount and it is difficult to accept this claim. Therefore, out of Rs.35,522/-, Rs. 5,800/- is liable to be deducted. After deduction the amount payable to the complainant comes to Rs.29,722/-. This amount would be just, fair and reasonable payable to the complainant. In the result, I proceed to pass the following:-<br /> ORDER<br /> <br /> 7. The Complaint is allowed. The opposite party No.2 is directed to pay Rs.29,722/- to the complainant within 30 days from the date of this order. In the event of non-compliance of the order within 30 days the said amount carries interest at 10% p.a from the date of this order till payment/realisation. <br /> 8. The complainant is also entitled for Rs.1,000/- towards costs of the present proceedings from the opposite party No.2.<br /> 9. Send the copy of this Order to both the parties free of costs immediately. <br /> 10. Pronounced in the Open Forum on this 13TH DAY OF FEBRUARY 2009. <br /> Order accordingly,<br /> <br /> <br /> PRESIDENT<br /> We concur the above findings.<br /> <br /> <br /> MEMBER MEMBER<br /> Rhr.,<br />