THE KARNATAKA STATE CONSUMER DISPUTES

REDRESSAL COMMISSION, BANGALORE. (ADDL. BENCH).

DATED THIS THE 9^th DAY OF JULY 2021

PRESENT

SRI RAVI SHANKAR – JUDICIAL MEMBER

SMT. SUNITA C.BAGEWADI - MEMBER

APPEAL NO. 1240/2018

Bajaj Allianz General Insurance Co., Ltd.,

Rep. by its Authorized Signatory,

Golden Heights, 4^th Floor, No.1/2,

59^th C Cross, 4^th “M” Block,

Rajajinagar, Bangalore-10.

……….Appellants.

(By Shri/Smt. Majoj Kumar M.R., Adv.,)

                                                -Versus-

Jacintha Martis, W/o Joseph Saldanha,

Major by age, Pompei Shade,

Behind Urwa Marigudi, Ashoknagar Post,

Mangalore-575 006.

(Served – not present)

:ORDERS:

BY SMT. SUNITA C. BAGEWADI  -  MEMBER

         This appeal is filed by the appellant/Opposite Parties being aggrieved by the order dated:29.06.2018 passed by Dakshina Kannada District Consumer Commission in C.C.No.257/2017. 

2.      The parties to the appeal shall be referred to as complainant and Opposite Parties respectively as per their rankings before the District Commission. 

3.      The brief facts of the complaint is that:-

         The complainant submitted that she is a Anganavadi Teacher and her husband is a retired Government servant.  She took medical insurance policy from Opposite Parties and obtained for hospital cash facility by paying extra premium of Rs.500/-.  The complainant further submitted that the complainant was admitted to Fr.Muller Medical College Hospital, Kankanady, Mangaluru on 05.05.2007 as inpatient for removal of the “Right Eye Immature Cataract and under ( L E) Phoco with foldable PC 10L implantation under LA on 06.05.2017 and on 08.05.2017.  The complainant further submitted that when the hospital authority sent the detailed medical bill for Rs.29,569/-, the Opposite Parties on 08.05.2017 re-coup the bill and sanctioned only Rs.12,000/- without any basis or there is no assigned in rejection of balance of Rs.17,569/- was paid by the complainant in cash and got discharged from the hospital.  The complainant further submitted that the legal notice was also served on the Opposite Parties, but the Opposite Parties was not complied the demand of the complainant.  Hence, alleged deficiency in service on the part of Opposite Parties and seeks direction against the Opposite Parties for payment of the balance amount with interest and compensation towards mental agony and cost of the proceedings.   

4.      The Opposite Parties appeared and filed their version, wherein the Opposite Parties admitted that the policy was issued by them and contended that there is no any deficiency in service or unfair trade practice on the part of Opposite Parties.  The Opposite Parties further contended that the insurance policy is a contract with terms and conditions of the policy,  the claim arrived is also processed within the precincts of the policy.  But the payment is subject to and governed by the terms and conditions of the policy.  The Opposite Parties further contended that after processing the medical claim relating to surgery of right eye immature cataract of complainant at Fr.Muller Medical College Hospital, Mangalore, the Opposite Parties released Rs.12,000/-.  The maximum amount allowed under the policy to the complainant was paid to the hospital.  As per the condition No.6(V), the maximum amount for which the complainant is entitled only Rs.12,000/-.  Hence, seeks dismissal of the complaint as there is no deficiency in service on the part of Opposite Parties.    

5.      After trail, the District Commission, Dakshina Kannada allowed the complaint and directed the Opposite Parties to pay Rs.17,569/- along with interest @ 7% p.a. from the date of complaint till the date of payment along with cost of Rs.10,000/- as a compensation and Rs.5,000/- towards cost of the complaint.

6.      Being aggrieved by the said order, the Opposite Parties are in appeal on various grounds.

7.      We have head the arguments on both sides.

8.      Perused the appeal memo, order passed by the District Commission and materials on record, we noticed that it is an undisputed fact that the respondent has obtained medical insurance policy from the appellant and also obtained for hospital cash facility by paying extra premium of Rs.500/-.  It is also an admitted fact that the respondent was admitted to Fr.Muller Medical College Hospital, Kankanady, Mangaluru on 05.05.2017 as an inpatient for removal of the Right Eye Immature cataract and under ( L E) Phoco with Foldable PC 10L Implantation under LA on 06.05.2017 and on 08.05.2017.

9.      The main allegations of the respondent is that when the hospital authority sent the medical bill of Rs.29,569/-, but the appellants on 08/05/2017 re-coup the bill and sanctioned only Rs.12,000/- and without any basis rejected the claim balance of Rs.17,569/- was paid by the complainant in cash and got discharged from the hospital.

10.    After perused the policy, we noticed that as per condition No.6(V), the Opposite Parties released Rs.12,000/-, the maximum amount in respect of the surgery for cataract per eye.  We agree for that,  However, the complainant/respondent has paid extra premium of Rs.500/- for hospital cash facility.  Hence, as per Clause “A” Cover 1) Medical Expenses, one of medical insurance policy, the respondent was entitled to claim expenses which she had incurred towards hospitalization and medical treatment.  However, in spite of settling the matter, the appellants repudiated the claim of balance of Rs.17,569/- even though the respondent has paid extra premium of Rs.500/- and tried to escape from their liability.  Hence, we found a clear case of deficiency of service on the part of appellant/Opposite Parties.  The complainant has paid Rs.500/- extract premium for hospitalization cash facility.  Hence, considering the insurance cover for complainant bearing in mind, nature of medical claim policy, the complainant is entitled to claim expenses which she had incurred towards hospitalization and medical treatment.  The District Commission after considering the facts and perused the materials on record and after calculation in respect of the room, nursing expenses, registration charges and service charges and other charges, as per Clause A(1) Cover, item (1) for 4 days, rightly passed an award.  Hence, in our opinion the judgment passed by the District Commission, Dakshina Kannada is legal and justified.  We do not found any merits in this appeal.  Hence, appeal is liable to be dismissed.  Accordingly, we proceed to pass the following:-   

:ORDER:

The appeal filed by the appellant/Opposite Parties is dismissed with no order as to costs.

The impugned order dated:29/06/2018 passed by the Dakshina Kannada District Consumer Commission in C.C.No.257/2017 is hereby confirmed.

The amount in deposit shall be transmitted to the concerned District Commission to pay the same to the Respondent/complainant.

Send a copy of this order to both parties as well as Concerned District Commission.

Sd/-                                                                                                                                         Sd/-

Member.                                                               Judicial Member.

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