Karnataka

StateCommission

A/1518/2013

The Manager, M/s. Star Health & Allied Insurance Co. Ltd., - Complainant(s)

Versus

Dr. Mahesh G. - Opp.Party(s)

S. Krishna Kishore

14 Jun 2022

ORDER

14.06.2022.

:ORDER:

BY SMT.RAVISHANKAR – JUDICIAL MEMBER

          We have heard the further arguments of appellant.  The respondent did not appear before this Commission to address his arguments.

2.       The learned counsel for appellant submits that the complainant had obtained Family Optima Insurance Policy bearing No.P/141123/01/2012/000620 which is valid from 30.04.2011 to 29.04.2012.  After issuance of the policy, the complainant was hospitalized on 10.01.2012 with a complaint of Chest Pain.  During the hospitalization, the hospital has sent cash less facility to this appellant, for which this appellant sought for some documents such as co-marbid condition and its duration, initial patient assessment and inpatient case sheets, cardiac enzymes and all positive investigation reports and line treatment/management obtained by the respondent with the Manipal Hospital, Tumkur as the complainant was known patient of diabetes mellitus/hypertension/ischemic heart disease and triple vessel disease through CAG.  But the complainant in spite of producing the documents has issued a legal notice and subsequently filed a complaint alleging deficiency of service on the part of this appellant.  After service of notice, the appellant appeared before the District Commission and again sought for the same documents, but the complainant has not produced the same. Thereafter the District Commission without considering their defense has directed them to pay Rs.1,00,000/- towards medical expenses which is against to the terms and conditions of the policy.  Hence, prays to set-aside the order passed by the District Commission.

3.       On going through the memorandum of appeal, certified copy of the order, we noticed that during hospitalization of the complainant, the appellant had sought for certain documents which the complainant ought to have produced for proceeding the claim, but the complainant has not produced the such documents and not stated any reason for non production of the said documents.  Even during the course of trial, the complainant has not produced the documents which sought for settlement of the claim.  We found, the District Commission has not observed that the Opposite Party/appellant has not repudiated the claim and but they only sought for certain documents to ascertain the claim.  Hence, we consider the District Commission made an error in awarding by directing the Opposite Party to pay Rs.1,00,000/- towards medical expenses.  We are of the opinion that in order to settle the claim, the complainant has to assist the appellant to ascertain the claim.  In the absence of such documents, the Opposite Parties are not able to settle the claim of the complainant.  It is only a negligence on the part of complainant.  Hence, we found there is no deficiency of service on the part of appellant.  As such the appeal is liable to be allowed.  Accordingly, we proceed to pass the following:-           

:ORDER:

The appeal is allowed.  The impugned order dated:27.08.2013 passed by the Tumkur District Consumer Commission in C.C.No.31/2013 is hereby set-aside.  Consequently, the complaint filed by the complainant is hereby dismissed.

          The amount in deposit shall be refunded to the appellant.

Forward free copy of this order to both parties as well as District Commission.

 

Lady Member.                                                      Judicial Member.

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