BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.317/2017

DATED ON THIS THE 4^th June 2018

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

B.A., LLB., - PRESIDENT  

                     2) Sri. Devakumar.M.C.                  

                                                B.E., LLB., PGDCLP   - MEMBER

Sri. Devakumar,M.C.

Member

1.     The complainant filed the complaint under section 12 of the C.P.Act 1986, against the opposite party, alleging deficiency in service and seeking a direction to pay Rs.15,000/- towards hospitalization expenses and damages of Rs.50,000/- for the mental agony, inconvenience caused, litigation expenses with such other reliefs.
2.      The complainant obtained a health insurance policy from opposite party, on payment of Rs.2,887/- towards premium.  The policy was valid for the period 15.05.2017 to 14.05.2018.
3.      Suffering from viral fever, he took treatment at Kamakshi Hospital, as in patient between 20.06.2017 to 23.06.2017, by incurring a sum of Rs.15,000/-.  After discharge from the hospital, made the claims under the policy by submitting all the necessary documents.  The opposite party neither repudiated nor settled the claims, despite of repeated demands.  Hence, the aggrieved complainant filed the complaint seeking reliefs.
4.     The opposite party appeared through their counsel without filing their version and submits that they are prepared to settle the claim.
5.     The complainant and opposite party led their evidence by filing affidavit and relied on several documents.  Opposite party filed written arguments and heard the counsel for complainant.  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 on the part of opposite party, for not settling the claims made under the health insurance policy 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 :-  In the negative

Point No.2:- As per final order

:: R E A S O N S ::

8.    Point No.1:- The complainant availed a medi-classic insurance policy (individual) from opposite party, on payment of Rs.2,887/- towards premium amount.  The said policy was in force between 15.05.2017 to 14.05.2018.
9.    The complainant was diagnosed for viral fever and on the advice of the doctor, got admitted as in-patient at Kamakshi Hospital, Mysuru on 20.06.2017 until discharge on 23.06.2017.  After discharge, he was under treatment as out-patient.
10. Claim form for Rs.13,806/- has been submitted to opposite party, along with all necessary documents.  On failure to settle the claims, filed the complaint and sought for the reliefs.
11. The opposite party filed a memo, and offered a D.D. for a sum of Rs.8,812/- in favour of the complainant, along with the relevant calculation sheet, explaining in detail about arrival of the above amount.
12. However, the complainant refused to accept the same and demanded suitable compensation for the belated settlement of claims and damages for the mental agony and inconvenience.  Later on, the complainant received the D.D. under protest.
13. Admittedly, the complainant availed a health insurance policy from opposite party, on payment of premium amount.  On availing treatment for viral fever, the hospital expenditure was claimed under policy.  However, the complainant prayed for Rs.15,000/- towards hospitalization expenses, but submitted the claim form of Rs.13,806/- only.  The opposite party, after considering and calculating the admissible claims, offered a D.D. for a sum of Rs.8,812/- on 25.01.2018 i.e. after lapse of about a month and a half from the date of filing this complaint.  Thereby, we opine that, there is no deficiency in service on the part of opposite party, as such, the complainant is not entitled for any reliefs sought.  Accordingly, the point No.1 is answered in the negative.

14. Point No.2:- In view of the above discussions on point No.1, we proceed to pass the following order:-

:: O R D E R ::

1. The complaint is dismissed.
2. Give the copies of this order to the parties, as per Rules.

(D