Complaint filed on: 11-01-2013 Disposed on: 11-03-2014 BEFORE THE BANGALORE IV ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BANGALORE URBAN DISTRICT, NO.8, SAHAKARA BHAVAN, CUNNINGHAM ROAD, BANGALORE – 560 052 C.C.No.18/2013 DATED THIS THE 11th MARCH 2014 PRESENT SRI.J.N.HAVANUR, PRESIDENT SRI.H.JANARDHANA, MEMBER Complainant: - Mrs.Anaja Raja #32, 1st Main, 1st Cross, Byreshwara Layout, Hennur Bande, Bangalore – 43 V/s Opposite party: - MAX BUPA HEALTH INSURANCE CO. LTD, # 30/1, C Block, 1st Floor, Vasihnavi Silicon terrace, (Tata Docomo building), Next to: Adugodi police station, Opp to: Star Bazar, Adugodi main Road, Bangalore-95 ORDER SRI.J.N.HAVANUR, PRESIDENT This is a complaint filed by the complainant against the OP, praying to pass an order, directing the OP to pay Rs.12,143=00. 2. The brief facts of the complaint can be stated as under. The complainant is a holder of health policy no.30078575201200 with the OP and the health policy validity is from 18-2-2012 to 17-2-2013 with a sum assured of Rs.2.00 lakhs. On 17-10-2012 the complainant had high fever and shivering and visited Dr.Raghunath Reddy, MD who treated the complainant as an out patient at Shree Vijayalakshmi hospital and Trauma Centre. On 18-10-2012 as the fever and shivering persisted, the complainant visited Santosh hospital, 6/1 Promanade road, Behind Coles park, Bangalore-95 and consultant physician Dr.Santosh Saklecha, MD and he examined and treated her as an out patient on 18-10-2012. But the conditions persisted and therefore Dr.Santosh Saklecha admitted the complainant on 19-10-2012 at Santosh Hospital. Before getting admitted, the complainant contacted Max Bupa at 12.27 p.m. on 19-10-2012 regarding admission and they told the complainant to go ahead and given reference no.172770. After admission as per the doctors advice all tests and treatment started and they did the dengue test, malaria test and those reports came as negative. But on the third day as platelet came down, once again the dengue test was done and the platelet count increased, the next day and result came as negative. After many bottles of IV fluids and various very high antibiotics, the complainant was treated and got discharged on 22-10-2012. The complainant contacted once again the OP and they told to submit the claim form alongwith all original papers from Santosh Hospital and accordingly the complainant did so on 26-10-2012 and message received from OP. After many phone calls to the OP and mails, the OP has denied the amount spent Rs.15,857=00 saying that this admission to hospital is linked to the earlier admission of herself to Manipal hospital, Bangalore in the month of Sept. 2012. The complainant was admitted to Manipal hospital for severe back pain and treated by Consultant Orthopedics Dr.KMK Verma. This admission to Santosh Hospital is totally different and treated for severe fever and shivering and doctors felt it may be dengue fever, very much prevailing at that time in Bangalore, but nothing to do with earlier admission to Manipal hospital. The OP has done total injustice to the complainant by denying first hospitalization claim to Manipal Hospital and for which the complainant has separately filed a complaint and for this Santosh Hospital admission, he has claimed Rs.15,857=00 + 18% interest from 22-10-2012 till date + Rs.50,000=00 as damage compensation for all the stress, trauma and anxiety and underwent by the complainant and her family members. After denying the above claim of the complainant suddenly on 26-12-2012, the OP has transferred Rs.14,237=00 to the account of complainant and after sending the amount by OP, the complainant is still to receive the following amount, balance Rs.15,857=00 - Rs.14,237=00 = Rs.1,620=00 + 18% interest for Rs.15,857=00 for two months and six days + Rs.10,000=00 as damage compensation for the unnecessary stress, trauma and anxiety caused by the OP, in total claim of Rs.12,143=00. Hence the present complaint is filed. 3. After service of the notice, the OP has appeared through its counsel and filed version, contending interalia as under: The complaint of complainant is not maintainable and it is devoid of merits. There is no negligence or deficiency of service whatsoever on the part of the OP in dealing with the concerned policy. The complaint is based on mere surmises and conjectures so the complaint is liable to be dismissed for want of cause of action. The complainant is trying to mislead the forum by stating wrong facts and the complainant is guilty of suppression of material facts. The OP admits that, it has insured the complainant vides policy no.30078575201200 and the same is valid from 18-2-2012 to 17-2-2013. The liability of the OP is limited to the terms and conditions of the policy of insurance issued. After taking the treatment the complainant has submitted discharge summary and other medical documents and on going through the same it is observed that the liability of the OP is limited to Rs.14,237=00 only as per the terms and conditions of the policy and accordingly the OP has transferred the above said amount to the account of the complainant on 24-12-2012. The complainant has submitted all medical records and bills pertaining to the treatment taken to the OP and on verification of the said medical documents, it is observed that in the inpatient bill a sum of Rs.500=00 is charged towards food and diet charges and another sum of Rs.1150=00 is charged towards nursing charges by the hospital authorities which is not payable as per the terms and conditions of the policy and so the same was deducted and after deducting the said amount Rs.14,237=00 was paid to the complainant. The OP has acted as per the terms and conditions of the policy and there is no deficiency of service on the part of the OP. The complaint has been filed by the complainant on experimental basis without any merits and the OP denies the other averments made in the complaint. Hence it is prayed to dismiss the complaint, in the interest of justice and equity. 4. So from the averments of the complaint of the complainant and objection of the OP, the following points arise for our consideration. 1. Whether the complainant proves that, the OP is negligent and there is deficiency of service on the part of the OP in not making settlement of her claim? 2. If point no.1 is answered in the affirmative, what relief, the complainant is entitled to? 3. What order? 5. Our findings on the above points are; Point no.1: In the Negative Point no.2: In view of the negative findings on the point no.1, the complainant is not entitled to any relief as prayed in the complaint Point no.3: For the following order REASONS 6. So as to prove the case, the complainant has filed her affidavit by way of evidence, and produced documents alongwith the complaint. On the other hand, one Anand Roop Choudhary who being the Head Legal working in the OP office has filed his affidavit and produced the copy of policy terms and conditions. We have heard the arguments of both parties and we have gone through the oral and documentary evidence of both parties meticulously 7. One, Anaja Raja, who being the complainant has filed her affidavit stating that, she is a holder of health policy no.30078575201200 with the OP and the health insurance policy is valid for a period from 18-2-2012 to 17-2-2013 with a sum assured of Rs.2.00 lakhs. On 17-10-2012 she had high fever and shivering and visited Dr.Raghunath Reddy, MD who treated her as an out patient at Shree Vijayalakshmi hospital and Trauma Centre. On 18-10-2012 as the fever and shivering persisted, she visited Santosh hospital, 6/1 Promanade road, Behind Coles park, Bangalore-95 and consultant physician Dr.Santosh Saklecha, MD examined and treated her as an out patient on 18-10-2012. But the conditions persisted and so Dr.Santosh Saklecha admitted her on 19-10-2012 at Santosh Hospital. Before getting admitted, she contacted Max Bupa at 12.27 p.m. on 19-10-2012 and they said to go ahead and gave reference no.172770 and also assured that the bill amount will be borne by them once all papers are submitted to them. After admission as per the doctors advice all tests and treatment started and they did dengue test and it came negative and they did malaria test and that also came negative. But on the third day as platelet came down, once again the dengue test was done and after treatment the platelet count increased, the next day and result came as negative. After many bottles of IV fluids and various very high antibiotics were given and finally got discharged on 22-10-2012, and she contacted once again Max Bupa and they told to submit the claim form alongwith all original papers from Santosh Hospital and they did so on 26-10-2012. After many phone calls to Max Bupa and mails, the OP has denied the amount spent Rs.15,857=00 saying that this admission to hospital is linked to the earlier admission to Manipal hospital, Bangalore in the month of Sept. 2012. She was admitted to Manipal hospital for severe back pain and treated by Dr.KMK Verma. This admission to Santosh Hospital is totally different and treated for severe fever and shivering and doctors felt it may be dengue fever, which was very much prevailing at that time in Bangalore, but nothing to do with earlier admission to Manipal hospital. Max Bupa was done total injustice to her by denying her first hospitalization claim and for which she has filed a complaint separately. So she has come up with the present complaint, so the complaint be allowed and grant relief as prayed for. 8. Let us have a cursory glance at the relevant document of complainant. Document no.1 of the complainant is the copy of claim form submitted by the complainant to OP claiming Rs.15,857=00 for having taken treatment in Santosh Hospital. Document no.2 consists of two copies of receipts issued by Santosh Hospital in the name of complainant dated 19-10-2012 and 18-10-2012 for having paid Rs.250=00 towards admission charges and consultation charges. Document no.3 consists of two receipts issued by Santosh hospital dated 19-10-2012 and 22-10-2012 in the name of complainant for having paid Rs.5,000=00 and 7,250=00 towards inpatient advance. Document no.4 is the copy of inpatient bill issued by Santosh Hospital in the name of complainant for having received Rs.12,250=00 towards various test and she was there in the hospital for 22 hours. The complainant has produced 7 copies of bills issued by Santosh Pharma for having purchased medicines. The Dengue, Typhoid and Malaria tests were conducted and all test reports of Dengue, Typhoid and Malaria came as negative. Discharge record of Santosh hospital is also produced and that discharge summary shows that, the complainant was admitted on 19-10-2012 and discharged on 22-10-2012. The complainant was admitted to hospital due to viral fever. Last document of complainant is repudiation letter of OP addressed to the complainant stating that, there was no active treatment given during the hospitalization. 9. Let us have a cursory glance at the material evidence of the OP. One. Anand Roop Choudhary who being the Legal head working in the OP office has stated in his affidavit that, the complainant has not approached this forum with clean hands, so it is liable be dismissed. There is no negligence or deficiency of service on the part of the OP. The policy of insurance is the evidence of the terms of the agreement between the insured and insurer. The promise of the insurer to indemnify the assured is subject to the terms, conditions and exceptions of the policy. The liability of the OP is limited to the terms and conditions of the policy of insurance issued. After taking the treatment the complainant has submitted discharge summary and other medical documents and on going through the same, it is observed that the liability of the OP is limited to Rs.14,237=00 only and the OP has transferred the above said amount to the account of complainant on 24-12-2012. In the inpatient bill a sum of Rs.500=00 is charged towards food and diet charges and another sum of Rs.1,150=00 is charged towards nursing charges by hospital authority which is not payable as per the terms and conditions of the policy and so the same was deducted. After deducting the said a sum, Rs.14,237=00 is paid to the complainant. The OP has acted as per the terms and conditions of the policy and there is no deficiency of service on the part of the OP, so the complaint be dismissed, in the interest of justice and equity. 10. The OP has produced copy of policy terms and conditions, wherein under clause no.2.1, it is stated as under: “They will cover medical expenses for (a) Doctor’s fee (b) Diagnostics procedures (c) Medicines, drugs and consumables (d) Intravenous fluids, blood transfusion, injection administration charges (e) Operation theatre charges (f) The cost of prosthetics and other devices or equipment if implanted internally during a surgical operation. (g) Intensive care unit charges” 11. As per the policy conditions, the OP has scrutinized the claim of the complainant and paid Rs.14,237=00 to the complainant by deducting Rs.1,650=00 being the amount towards food and diet charges and nursing charges. 12. So taking the material evidence of the complainant and compare the same with the oral and documentary evidence of OP, it is made manifest that, after going through the claim and documents of complainant, the OP has made careful scrutiny of claim form and other medical documents submitted by the complainant and out of the claim of Rs.15,857=00, Rs.500=00 was deducted towards food and diet charges and an amount of Rs.1,150=00 was also deducted which was charged towards nursing charges as per the terms and conditions of the policy and paid Rs.14,237=00 to the complainant as per the policy condition. In fact, the OP has acted in accordance with the terms, conditions and exception of the policy and we do not find any negligence or deficiency of service on the part of the OP and on account of it, there is no question of paying Rs.1,650=00, interest and damages to the complainant as prayed in the complaint. Since the policy taken by the complainant is subject to the terms, conditions and exception of the policy. The OP has acted in accordance with the terms and conditions of the policy and there is no negligence or deficiency of service on the part of the OP. Whatever the complainant was entitled as per the policy condition, the OP has paid the amount and there is no question of paying the balance amount + interest on the entire claim amount and compensation as prayed in the complaint, and as such, we are of the considered opinion that, the oral and documentary evidence of OP placed before the forum are more believable trustworthy and acted upon than the material evidence of complainant, so we hold that, the complainant who comes to the forum seeking relief has failed to prove with clear cogent and consistent material evidence that, the OP is negligent and there is deficiency of service on the part of the OP in not making settlement of her claim, and according, we answer this point in a negative. 9. In view of the negative finding on the point no.1, the complainant is not entitled to any relief as prayed in the complaint. So, we answer this point in a negative. In the result, for the foregoing reasons, we proceed to pass the following order. ORDER The complaint of complainant is hereby dismissed. No costs. Supply free copy of this order to both parties. (Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open forum on this the 11th day of March 2014). MEMBER PRESIDENT |
