BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.7/2017

DATED ON THIS THE 30^th June 2017

      Present:  1) Sri. H.M.Shivakumara Swamy

B.A., LLB., - PRESIDENT   

    2) Smt. M.V.Bharathi                    

                                   B.Sc., LLB., -  MEMBER

                     3) Sri. Devakumar.M.C.                  

                                          B.E., LLB., PGDCLP,    - MEMBER

Sri DEVAKUMAR.M.C,

Member

1.     The complainant has filed the complaint under section 12 of the C.P.Act, 1986, against the opposite parties, alleging deficiency in service and seeking a direction to pay Rs.45,365/- and to pay Rs.50,000/- compensation of Rs.50,000/- towards the mental agony and cost of the proceedings with such other reliefs.
2.     The complainant taken the “Health Suraksha Policy-Silver Plan” from opposite party No.1, for a sum assured Rs.2,00,000/-.  The insurance policy was in force between 21.08.2015 to 20.08.2016.  On submission of the proposal form, with all relevant information, the policy was issued on receipt of premium of Rs.8,813/-.
3.     The complainant, got admitted and took treatment at Ramakrishna Hospital by spending a total sum of Rs.3,875/-. After getting discharge, he got admitted to Apollo Hospital, where he was treated for Severe Anemia Nutritional deficiency, acute febrile illness with thrombocytopenia dengue and spent about Rs.41,490/-.  Claim was made by submitting all the documents.  The opposite parties repudiated the claims.  Hence, the aggrieved complainant filed the complaint seeking reliefs.
4.     The opposite parties admits the issue of “Health Suraksha Policy-Silver Plan” and pleads the same was issued from its Mumbai office.  The policy never covered the cashless facility, as such, the claim to pay the hospital bills were refused.  The opposite party No.1 sought for certain documents vide letter dated 29.09.2016 and 05.11.2016, but the complainant failed to furnish the same, which lead to closure of the claim.  Therefore, there is no deficiency in service and unfair trade practice by opposite parties, as such pleads, complainant not entitled for any reliefs and prays for dismissal of the complaint with costs.
5.     To prove the facts, the complainant and opposite parties have led evidence by filing their respective affidavit and relied on several documents.  Written arguments filed by both side.  Heard the oral submissions of the respective counsels.  Perusing the material on record, matter posted for orders.
6.     The points arose for our consideration are:-

1. Whether the complainant establishes the deficiency in service and unfair trade practice by the opposite parties, in not settling the claims made under the “Health Suraksha Policy – silver plan” and thereby he is entitled for the reliefs sought?
2.  What order?

7.    Our findings on the aforesaid points are as follows:

Point No.1 :- Partly in the affirmative.

Point No.2 :- As per final order for the following

:: R E A S O N S ::

8.    Point No.1:- The complainant obtained a “Health Insurance Policy – Silver Plan” from opposite party No.2, which is the branch office of opposite party No.1, on 21.08.2015.  The policy was for a sum assured of Rs.2,00,000/-, and the same was in force between 21.08.2015 to 20.08.2016.  the opposite parties assured the policy coverage for pre-hospitalization, day procedures, organ donor.   
9.    The complainant provided all relevant information in the proposal form, including the medical history.  He got admitted to Ramakrishna Hospital and duly obtaining treatment, by spending Rs.3,875/- got discharged.  Later admitted to Apollo Hospital, where he was diagnosed as severe anaemia of nutritional deficiency, acute febrile illness with thrombocytopenia, dengue, and got treated for a period of three days.  The hospital preferred the bill for a sum of Rs.41,490/-, to opposite parties, calling for settlement under the Health Suraksha Policy.  The opposite party’s not settled the claim.  The complainant settled the hospital expenses by himself and got discharged.  The requests made to settle the claim amount was went in vain.  Hence, the aggrieved complainant filed the complaint and sought for the reliefs.
10. Opposite parties contended that, the policy has been issued by Mumbai office and hence the Forum lacks jurisdiction, as such the complaint is liable to be dismissed.  Further, the opposite party No.1 called for certain documents to process the claims, were not furnished by the complainant which resulted in closure of the claim.  As per the policy terms and conditions, the complainant was required to furnish all the necessary documents to settle the claims, which the complainant failed to comply.  As such, the claim has not been repudiated, but the same has been closed for want of documents.  So contended that, there is no deficiency in service by them and the complainant is not entitled for any compensation as sought.  As such, prayed for dismissal of the complaint with costs.
11. The complainant filed the complaint alleging deficiency in service and unfair trade practice, regarding non settlement of his hospital expenses under the “Health Suraksha Policy – silver plan”.  However, to settle the claim, the opposite party sought for certain specific documents relating to his previous treatment obtained, on failure to furnish the same despite of repeated reminders, the opposite parties have closed the claims for want of documents from the complainant.  Further, the opposite party, contended that the claims may be re-considered if the required documents are furnished, subject to the conditions.  In view of the same, we opine that, the complainant ought to furnish the required documents to opposite party, to settle the claims under the policy.  As such, the allegation of deficiency in service and unfair trade practice is justifiable and the complainant is not entitled to any compensation.  Accordingly, the  Point No.1 is answered partly in the affirmative.
12.  Point No.2:- In view of the above observations made in point No.1, we proceed to pass the following

:: O R D E R ::

1. The complaint is hereby allowed in part.
2. The complainant is hereby directed to furnish the relevant documents to opposite parties in order to process the claims, within 30 days of this order.  Further, the opposite parties are hereby jointly and severally directed to settle the claim, as per policy conditions within 30 days, from the date of receipt of required documents by the complainant.
3. Failing to comply the order, the opposite parties are liable to pay penalty of Rs.50/- per day to the complainant until compliance.
4. The complainant is not entitled for any other reliefs.
5. In case of default to comply this order, the opposite parties to undergo imprisonment and also liable for fine under section 27 of the C.P.Act, 1986.
6. Give the copies of this order to the parties, as per Rules.

 (Dictated to the Stenographer transcribed, typed by her, transcript corrected by us and then pronounced in open court on this the 30^th  June 2017)