DISTRICT CONSUMER DISPUTES REDRESSAL FORUM MYSORE No.1542/F, Anikethana Road, C and D Block, J.C.S.T. Layout, Kuvempunagara, (Behind Jagadamba Petrol Bunk), Mysore-570009. consumer case(CC) No. CC/09/407
IN THE DISTRICT CONSUMERS DISPUTES REDRESSAL FORUM AT MYSORE PRESENT: 1. Shri.A.T.Munnoli B.A., L.L.B (Spl.) - President 2. Shri. Shivakumar.J. B.A., L.L.B., - Member CC 162/09 DATED 05.12.2009 ORDER Complainant R.Latha, R/at No.741, 10th Main, C Block, 3rd Stage, Vijayanagar, Mysore. (By Sri. B.N.Ramachandra, Advocate) Vs. Opposite Parties 1. The Manager, Medicare TPA Services (I) Pvt. Ltd., No.6, Bishop Lefroy Road, Kolkata-700020. 2. The Manager, Medicare TPA Services, F-3, No.10, 1st Floor, 13th Main, Naveen Apartments, Vasantha Nagar, Bangalore-52. 3. The Manager, Bajaj Allianz Life Insurance Corporation, Mythri Arcade, 1st Main Road, Saraswathipuram, Mysore. (EXPARTE) Nature of complaint : Deficiency in service Date of filing of complaint : 02.11.2009 Date of appearance of O.P. : - Date of order : 02.12.2009 Duration of Proceeding : - PRESIDENT MEMBER Sri. A.T.Munnoli, President 1. Under Section 12 of the Consumer Protection Act, the complainant has filed the complaint against the opposite parties, seeking direction to pay a sum of Rs.71,876/- the mediclaim. 2. It is alleged in the complaint that, the complainant is a member of the opposite parties with policy No.0059977168 Health Care, valid from 27.08.2007 to 27.08.2009. Annual premium was Rs.2,367/-. The complainant was admitted at A.G.Hospital and Research Centre, Mangalore on 04.11.2008 for surgery and was discharged on 01.12.2008. Opposite parties settled the hospital bill and remitted Rs.80% of the total bill to the hospital. The complainant again admitted in the said hospital for post-operative treatment on 27.12.2008 and discharged on 02.01.2009. Total expenditure incurred for hospitalization is Rs.40,941/-. The hospitalization and surgery as well as expenditure incurred for series investigation at Mangalore and Karnataka Cardio Diagnostic Centre, Mysore amounting to Rs.66,876/- was sent to the first and second opposite parties. They have acknowledged the receipt of the claim, by the letter dated 01.12.2009. They called upon the complainant to submit some more documents to finalize the bill. The clarification sought was furnished by the doctor by letter dated 16.05.2009. Legal notice was also sent. But, the opposite parties have not settled the claim. On these grounds, it is prayed to allow the complaint. 3. All the opposite parties were duly served with notice, but have remained exparte. 4. To prove the facts alleged in the complaint, the complainant has filed her affidavit and produced certain documents. We have heard the learned advocate for the complainant and perused the records. 5. Now the points arises for consideration are as under:- 1. Whether the complainant has proved any deficiency in service on the part of the opposite parties and that she is entitled to the reliefs sought? 2. What order? 6. Our findings are as under:- Point no.1 : Partly in the Affirmative. Point no.2 : As per the order. REASONS 7. Point no. 1:- Without repeating the facts mentioned at the beginning, grievance of the complainant is that, the opposite parties have not paid a sum of Rs.62,876/-. 8. In support of the claim made, complainant has produced Xerox copy of inpatient bill at page 48 of A.G.Hopsital, Mangalore and the net amount payable is Rs.40,941/-. At page 50 of the documents, letter of the opposite parties to the complainant, is produced. In this letter, there is mention that, detail break-up in respect of the amount of Rs.20,736/- was required. At page 51 of the documents, copy of the letter of the doctor is produced. Wherein it is stated that, said amount inclusive of operation theatre charges, anesthesia charges, and oxygen charges. It is mentioned, no separate break-ups are available. On page 52, other requirements are stated. But, the fact remains that, as the opposite parties demanded break-up of the said amount has not been furnished by the complainant. 9. Even otherwise, except the bill at page 48, to support the remaining amount, the complainant has not produced the bills particularly the amount said to have been spent or paid to Karnataka Cardiac Diagnostic Centre, Mysreo. Certain other bills are produced, pertaining to out patient. But, as could be seen from the terms of the policy, opposite parties are liable to pay only if the complainant insured had taken treatment as inpatient. 10. Further, as mentioned in the policy, opposite parties are liable to pay only 80% of the bill. Taking into consideration of this aspect and the bill produced at page 49, we are of the opinion that, the complainant is entitled to only 80% of Rs.40,941/- that is Rs.32,752.80 rounded to Rs.32,000/- only. 11. At the cost of repetition, opposite parties though duly served have not disputed the claim made by the complainant and moreover, as per the letter at page 50, it was informed by the opposite parties that, medical claim documents were received and already processed by the opposite parties. 12. Accordingly, our finding on the point is partly affirmative. 13. Point No. 2:- Considering the discussion made above and conclusion arrived at, we pass the following order:- ORDER 1. The Complaint is partly allowed. 2. All the opposite parties jointly and severally shall pay a sum of Rs.32,000/- to the complainant the medical claim, within a month from the date of this order, failing which, the amount shall carry interest at the rate of 10% p.a. 3. The opposite parties further shall pay a sum of Rs.3,000/- towards cost of the proceedings. 4. Give a copy of this order to each party according to Rules. (Dictated to the Stenographer, transcribed by her, transcript revised by us and then pronounced in the open Forum on this the day 2nd December 2009) (A.T.Munnoli) President (Shivakumar.J.) Member
