D.O.F:09/07/2019
D.O.O:30/07/2021
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.No.135/2019
Dated this, the 30th day of July 2021
PRESENT:
SRI.KRISHNAN.K :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
Jayalakshmi, aged 40 years
W/o. Raghurama, Anugraha quarters
Near Bolukatta Ground, : Complainant
Upper Bazar, Badiadka, Perdala Post,
Kasaragod Taluk and District.
(Adv: Subhash Bozz.V.M)
And
- Dr. K. Mukund Medical Officer,
Omega Hospital (P) Ltd, Mahaveer Circle,
Kankanady, Mangalore .
- The Administrator, Omega Hospital (P) Ltd, : Opposite Parties
Mahaveer Circle, Kankanady , Mangalore.
- The Medical Officer, Beedi Workers Welfare
Dispensary, Manjeshwar
ORDER
SRI.KRISHNAN.K :PRESIDENT
The complaint filed under section 12 of Consumer Protection Act. The case of the complainant is that she is a beedi roller by profession working under K.M.Abdulla, Bharath beedi contractor. Her mother also beedi roller who has undergone Angiogram and Angioplasty from the hospital of Opposite Party No.1 and Opposite Party No.2.
2. The complainants’ mother fell ill. They belonged to very poor family. The Opposite Party No.1 and 2 is the recognized hospital for treatment of beedi workers coming under beedi workers welfare fund. Hence her mother is admitted in Opposite Party hospital for treatment on 20/03/2015 and discharged on 10/04/2015.
3. Total medical expenses of Rs. 1,30,000/- is arranged by borrowing and pledging of gold ornaments with assistance of Opposite Party that amount will be re-imburshed by credit to the account of complainant. But surprisingly Opposite Party No.3 repudiated the claim on the ground of delay as per letter dated 06/05/2019 received on 10/05/2019. Thus there is deficiency in service and negligence on the part of Opposite Party. Complainant therefore filed the complaint for directing Opposite Party to pay Rs.2,00,000/- to the complainant towards medical expenses and costs.
4. The Opposite Party No.3 appeared and filed version. According to Opposite Party No.3 Beedi workers suffering from heart diseases are covered by scheme re-imbursement by ministry of labour and employment. Permission for treatment for availing medical treatment was granted with instruction to submit the claim in form No.B only signed by authorities with supporting documents to be submitted immediately. But claim is made only on 30/03/2019 after a lapse of four years without any supporting documents. Thus claim is repudiated. The claim is not submitted through Medical Officer Manjeshwar. In claiming benefits necessary proceedings to be followed and since claim is not submitted as per requirements it is repudiated.
5. Notice to Opposite Party No.1 and 2 served not appeared and set exparte.
6. The complainant filed chief examination affidavit and was not cross examined. Ext A1 to A11 documents marked from her side. Ext A1 and A2 are copy of claim request. Its reply is marked as Ext A3, ID card is Ext A4 and Ext A5 discharge summary. Medical report is Ext A6 and A7, bill is Ext A8, Ext A9 is claim forwarding letter, Ext A10 covering letter explaining delay and Ext A11 is the repudiation letter by Opposite Party No. 3.
7. Considering the rival contentions following points arise for consideration for decision.
a) Whether complainant is entitled to re imbursement of medical claim and if so whether repudiation on the ground of delay is justifiable.
b) Whether there is any deficiency in service from Opposite Parties
c) Whether complainant is entitled for compensation? If so for what reliefs?
8. The complainant’s case is that her mother is beedi roller fell ill and she is coming under the beedi workers welfare fund. Her treatment expense claim was repudiated by Opposite Party No.3 for not valid grounds. The Opposite Party No. 3 rejected the claim on the ground that the claim is not made in time.
9. When patient is suffering from heart diseases and angioplasty is done we cannot expect the patient or relatives approach for insurance claim immediately. Even if there is delay or procedural lapse, mex technicalities should not stand in the way of disbursement of medical claim if really patient is eligible for the claim otherwise.
10. The Opposite Party No..3 rejected the claim only on the grand of delay which is not justifiable by law. The Opposite Party No.3 has no case that complainant is not entitled to re-imbursement of medical claim as per rules. Hence repudiation on the grand of delay is legally unjustifiable and hence not acceptable as per law.
11. In Om praksh Vs Reliance General Insurance and Anr (Civil appeal N0.15611 of 2017) Honourable Supreme court held that the decision of the insurer to reject a “claim has to be based in valid grounds. Rejection of the claims on purly technical grounds in a mechanical manner will result in loss of confidence of policy- holders in the insurance industry. If the reason for delay in marking a claim is satisfactorily explained, such claim cannot be rejected on the ground of delay”. It was further held that “ it would be fair and reasonable to reject genuine claims which had already been verified and found to be correct by the investigator. The condition regarding the delay shall not be a shelter to repudiate the insurance claims which have been otherwise proved to be genuine”. It is therefore we hold that rejection of insurance claim by Opposite Party No.3 is unjustifiable and not acceptable as per law. The commission finds that complainant is entitled to the benefits claimed and Opposite Party No.3 is liable to re-imburse the claim ignoring the delay which is explained satisfactory. Thus issue No. 1 is found in favor of complainant.
12. The complainant alleged deficiency in service and negligence but not supported by any evidence. Admittedly claim reached the office of Opposite Party No.3 delayed and have the reply rejecting the claim. There is no deficiency in service in processing the claim and complainant is not entitled to any compensation but entitled to claim of cost of litigation. The Opposite Party No.1 and 2 being the hospital and doctor who collected their charges are not liable to re-imburse though are impleaded as eo nomino parties. The Opposite Party No.3 is found liable to meet the claim of complainant.
In the result complaint is allowed in part. Opposite Party No. 3 is directed to allow the re-imbursement of medical claim of her mother Lalitha to the tune of Rs. 1,30,000/- as covered by discharge summary bill issued by Opposite Party No. 1 and 2 with interest at 6% per annum from the date of submission of claim till payment along with costs of Rs. 5000/-(Rupees Five thousand only) within 30 days of the receipt of the order.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Identity Card
A2 &A3 - Discharge bill
A4- Coronary Angiogram
A5- Coronary Angioplasty
A6- Coronary Angiogram
A7-Coronary Angioplasty
A8- Discharge bill
A9- Claim forwarding letter.
A10- Covering letter explaining delay
A11- Repudiation letter by OP.3
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Senior Superintendent
Ps/
