BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION BAGALKOT.

C.C.No.19/2020

Date of filing: 14/02/2020

  Date of disposal: 13/09/2021

P R E S E N T :-

              V/s     

JUDGEMENT DELIVERED BY SMT.SHARADA.K.PRESIDENT

1.      This is a Complaint filed by the complainants under Section 12 of the Consumer Protection Act, 1986 (herein after referred to as Act) against the Opposite Parties (in short the “OPs”) to refund the entire claim amount of the complainants alongwith interest at the market rate and pay Rs.46,887/- towards compensation to the complainants and costs of the litigation and any other reliefs.

2.      The facts of the case in brief are that;

          The case of the complainants that, the complainant No.1 has got the MEDI ASSIST health Insurance Policy bearing No.500100/28/17/P1/10709792 through OP.No.2 & 4 Bank for myself as well as my dependents the said policy covering for sum assured of Rs.4,00,000/- from 01.10.2017 to 30.09.2018, the OP.No.1 is service provider to the said policy and further the complainant No.2 admitted on 02.01.2018 in Sangam Hospital in Allhabad and discharged on 06.01.2018 during this period hospital expenses of Rs.22,987/- and pre-Hospitalization expenses of other hospital of Rs.17,900/- and other Health Check-up expenses of Rs.6,000/- is totally of Rs.46,887/- bill claimed by the Complainant No.1 for reimbursement to the OP.No.1 on dtd:02.04.2018 and further the above said bill, the complainant has paid Rs.21,000/- through digital payment and he produced original documents like reimbursement form, Sangam Hospital Discharge Card, Sangam Hospital Final Bills, other pre-Hospitalization bills and digital payment receipts via claim No.16756032 to the OP.No.1. But, inspite of that, complainants claim was closed, because of proper query reply not being submitted on time and without giving prior intimation or notice.

          It is further contended that, the complainant mail conversation records on 16^th May 2018, you stated that, the final bill is of Rs.25,000/-, but the actually it was final bill of Rs.21,000/- only, which shows OP.No.1’s negligence in processing the claim in right faith of serving the service to society. On the same date complainant replied to mail and given consent for partial claim also, but the OP.No.1 was without seeing the documents properly and rejected the complainants claim. Hence, it clearly shows that, the OP.No.1 and his official have cheated with complainants by way of taking the original hospital bill documents thereby; there is a negligence and deficiency in service on the part of the OPs. Hence, the complainants are constrained to file this complaint.

3.      The Commission registered a case and issued notice to the Ops. After service of the notices, the OP.No.1 & 2 have not appeared before this commission. Hence, this commission has considered the OP.No.1 & 2 are placed Ex-parte and OP.No.3 has appear before this Commission, but neither filed written version nor contest the case and OP.No.4 appeared through his counsel and filed his written version.

The OP.No.4 has denied all the averments in the complaint and further contended that, the complainants have wrongly made this OP as party to the complaint and this OP office had not issued the above said policy, the policy had been issued by Bangalore Office and this OP is not proper party and further the said policy is subject to IRDA (Health Insurance) Regulations 2013 and IRDA Protection policy holders interest regulations 2002 as amended time to time as per conditions of the policy. The claimant should submit all supporting documents relating to the claim must be filed with the office Third Party Administrator within 30 days from the date of discharge from the hospital and further the claim of the complainant is not rejected it was closed since complainant was not replied the query properly on time and acted upon the terms and conditions and IRDA rules, regulations. Hence, there is no deficiency of service on the part of Ops and complainant has not approached the Hon’ble Forum with clean hands. Therefore, the complainant has approached the OP.No.1 with required documents to settle his claim and OP.No.4 prayed for dismissed the complaint with compensatory costs.

4.      The complainant No.1 has filed his chief affidavit along with  documents which are as follows;

Now, on the basis of these facts, the following points arise for our consideration:

1. Whether the complainants have proved that, there is deficiency of service on the part of the OPs for not settling the medical claim amount?
2. What order?

5.      Our findings to the above points are as under:       

1. Partly in the Affirmative.
2. As per the final order for the following:

                                  :: R E A S O N S ::

6.     POINT NO:1:-  We have perused the pleadings of the complainants and the evidence and documents placed on record and there is no dispute regarding MEDI ASSIST health insurance policy No.500100/28/17/P1/10709792 through OP.No.2 & 4 Bank for myself as well as my dependents and the said policy up to the year 2017-18, the complainants have claiming as per policy covers sum assured of Rs.4,00,000/-, the policy is cover to the extent of Rs.4,00,000/- and complainants have claiming Rs.46,887/-, the said contention stated by the complainants by producing reimbursement claim form which is marked as Ex.C-4 and affidavit evidence and more ever the complainant No.1 has send mail to the OP.No.1 on dtd:02.04.2018 to resolve the issue and help me to get all my claim amount of Rs.46,887/-. In our consider opinion that, once the claim form has been filed by the complainants before the OP.No.1 by mentioning an amount of Rs.46,887/- and the said document has not disputed by the complainants, it means, the complainants stick up for Rs.46,887/- towards mediclaim expenses incurred and further as per discharge certificate issued by Dr.Vibha Raj Sangam Hospital, Allhabad final bill on dtd:06.01.2018 which is marked as Ex.C-5, which is produced by the complainants, wherein date of admission and discharge has been mention and it clearly revels that, the date of admission is 02.01.2018 and date of discharge 06.01.2018 and total paid amount is Rs.21,000/-. It means that, the complainant No.2 is indoor patient, not out door patient and further the complainant No.2 has incurred Pre-hospitalization expenses of other hospitals and health check-up expenses and description about treatments of Rs.25,887/, but we are consider only Rs.13,407/- for other expenses. Hence, the contention taken by the complainant No.1 is acceptable, under such circumstances and looking to the facts and circumstances of the case, the complainants are entitled Rs.21,000 + 13,407 = Rs.34,407/- it would be proper and justifiable.

On the other hand, the OP.No.1 has rejected the claim of the complainant that to submit all supporting documents relating to the claim must be filed with the office Third Party Administrator within 30 days from the date of discharge from the hospital and further the claim of the complainant is not rejected it was closed since complainant was not replied the query properly on time and acted upon the terms and conditions and IRDA rules, regulations, itself is suffice to hold that, the act of the OP.No.1 it amounts to deficiency of service on the part of the OP.No.1. Therefore, it is crystal clear that, the OP.No.1 is committed deficiency of service on the part of the OP.No.1 for not settling medical bill as per MEDI ASSIST health Insurance policy bond and conditions. For that proposition, we would like to refer a decision of Hon’ble High Court of Patna reported in AIR 2013 Patna 113, wherein the lordship observed that, a mediclaim policy of any insurance company is aimed at covering the insured against expensive treatment of his ailment, which otherwise he may not be in a position to afford and meet his end on account of it. 

Now, coming to the quantum of the claim that, the complainants are claimed Rs.46,887/- as mediclaim expenses, in order to prove the said claim, the complainants have failed to substantiate the case as claimed, admittedly the complainants have filed claim form before the OP.No.1 by mentioning an amount of Rs.46,887/-  and the said documents have not disputed by the complainants. In our consider view that, the complainants are entitled to claim of Rs.34,407/- towards mediclaim expenses incurred and before filing of this complaint, the OP.No.1 has credited Rs.6,623/- on dtd:09.01.2020 to the complainant No.1 savings account for medicalim amount is not proper. Hence, we are of the view that, the complainants are entitled the medicalim expenses of Rs.27,784/- (Rs.21,000/- + 13,407 = Rs.13,407 – 6,623) difference amount of the medicalim  and also the complainants are entitled for compensation of Rs.5,000/- towards mental agony and also Rs.3,000/- towards costs of the proceedings.  The claim against OP.No.2 & 3 are dismissed. Accordingly, we answer to Point No.1 in the partly affirmative and we proceed to pass the following:

O R D E R

1.      The complaint filed by the complainants are hereby partly allowed.

2.      The OP.No.1 & 4 shall pay a sum of Rs.27,784/- towards the medical bills to the complainants.

3.      The OP.No.1 & 4 shall pay a sum of Rs.5,000/- towards mental agony and Rs.3,000/-towards costs of the proceedings to the complainants.

4.      The OP.No.1 & 4 are granted 10 weeks time for compliance of this order, failing which liable to pay interest
@ 8% p.a. from the date of this order till its realization. 

5.      Send the copies of this order to the parties free of cost.

(Dictated to the Stenographer, transcribed by him, corrected and then pronounced by me in the Open Commission on this 13^th day of September, 2021).