CC Filed on 06.07.2010<br /> Disposed on 06.09.2010<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KOLAR.<br /> <br /> Dated: 06th day of September 2010<br /> <br /> PRESENT:<br /> Sri. G.V.HEGDE, President.<br /> <br /> Sri. T.NAGARAJA, Member.<br /> Smt. K.G.SHANTALA, Member.<br /> ---<br /> <br /> Consumer Complaint No. 86/2010<br /> <br /> Between:<br /> <br /> <br /> Sri. A.V. Ananda,<br /> S/o. Venkatappa,<br /> R/a 5th Cross, 1st Main,<br /> Muneshwara Nagara,<br /> Kolar Town, <br /> Kolar Taluk.<br /> <br /> <br /> (By Advocate Sri. H.V. Krishne Gowda ) <br /> <br /> <br /> V/S<br /> <br /> 1. Medi Assist India Pvt. Ltd.,<br /> No. 49, Shilpa Vidya, 3rd Floor,<br /> 1st Main, Sarakki Industrial Layout,<br /> J.P. Nagar, Phase III,<br /> Bangalore – 560 078. <br /> <br /> <br /> 2.Dr. Sunil V. Nukapur,<br /> Orthopaedic Surgeon,<br /> Proprietor,<br /> Dr. Nukapur Hospital,<br /> Sharada Talkies Road,<br /> Kolar – 563 101.<br /> <br /> <br /> (Advocate for OP.2 Sri. N. Venkateshappa) <br /> <br /> <br /> <br /> <br /> ….Complainant<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> ….Opposite Parties<br /> <br /> <br /> <br /> <br /> ORDERS<br /> <br /> This is a complaint filed under section 12 of the Consumer Protection Act, 1986 praying for a direction against the opposite party No.1 to pay a sum of Rs.50,000/- to the complainant for medical claim and another Rs.50,000/- towards compensation for mental agony due to deficiency in service of OP.1 with costs and interest, etc., <br /> <br /> 2. The material facts of complainant’s case may be stated as follows:<br /> That the complainant obtained medi claim policy for Rs.1,00,000/- from Reliance General Insurance Company Limited having its Registered Office Reliance Centre, 19, Walchand Hirachand Marg, Ballard Estate, Mumbai – 400 001 under insurance policy No. 28251026039501 with T.P.I.D No. 4005360603 for the period from 09.04.2009 to 08.04.2010. The complainant had also obtained similar policies for the last three years. OP.1 is the Third Party Administrator (TPA) for the said company for Bangalore area. <br /> <br /> The complainant was suffering from hip joint pain and back pain. He was got admitted on 21.03.2010 in Dr. Nukapur Hospital situated at Kolar which is one of the approved hospitals by the said Reliance General Insurance Company. Before admission he furnished relevant records and particulars with a view to obtain cashless facility for his treatment in the said hospital. It is alleged that OP.1 (TPA) advised the hospital authority to extend the said benefit to complainant. It is alleged that OP.2 the proprietor of Dr. Nukapur Hospital, Kolar gave the required treatment and also referred the complainant to Dr. Dharmananda, who is Specialist in Rheumatology at Chanre Diagnostic at Bangalore. The said Specialist also investigated and treated the complainant and advised some follow up measures. The complainant was discharged from Dr. Nukapur Hospital, Kolar on 01.04.2010. It is also alleged that he spent huge amount for undergoing different Laboratory tests including M.R.I. and other expenses.<br /> <br /> It is alleged that on the date of discharge i.e. on 01.04.2010 the hospital authorities insisted for payment of hospital bills stating that OP.1 had intimated to recover the bill amount from the complainant directly and to advise complainant to submit the claim before OP.1 directly for payment to him. The complainant without any alternative paid the hospital bill at the time of his discharge from his pocket. It is alleged that subsequently on 08.04.2010 the complainant preferred the claim before OP.1 with necessary original bills and other documents, but OP.1 did not respond evenafter several requests and also a legal notice dated 08.06.2010 inspite of its service. <br /> <br /> 3. OP.2 appeared and supported the case of complainant by filing version. It is stated by OP.2 that OP.1 had intimated to extend the cashless facility to complainant. The acknowledgement of service or the unserved postal cover addressed to OP.1 through R.P.A.D by this Forum was not returned. The legal notice previously sent by complainant to OP.1 was served to the same address of OP.1 and OP.1 had not given any reply to the legal notice. Therefore the service of notice sent by this Forum on OP.1 was held sufficient. OP.1 was absent on the date of first hearing or subsequently and its version was not filed. <br /> <br /> 4. The complainant filed affidavit in support of his case and produced relevant records. Heard the Learned Counsel for complainant. During the arguments on perusal of the terms and conditions of the policy, a portion of the claim was found not covered on certain heads. The Learned Counsel for complainant was asked to file a memo of calculations disclosing the amount that could be claimed under the terms and conditions of the policy. Accordingly he filed the memo of calculation showing the permissible amount under the policy. The said claim comes to Rs.27,650/-. It is supported by bills and vouchers. <br /> <br /> 5. We have also went through the documents and found that the amount now claimed for Rs.27,650/- is admissible for reimbursement. For the above reasons we pass the following: <br /> O R D E R<br /> <br /> The complaint is allowed with costs of Rs.1,000/-. OP.1 and Reliance General Insurance Company Limited having its Registered Office Reliance Centre, 19, Walchand Hirachand Marg, Ballard Estate, Mumbai – 400 001 shall pay jointly and severally Rs.27,650/- to complainant with interest at 8% p.a. from 21.04.2010 till the date of payment. The amount due under this order shall be paid within 4 weeks from the date of this order.<br /> <br /> Dictated to the Stenographer, corrected and pronounced in open Forum this the 06th day of September 2010.<br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br />