Date of Filing:17.06.2008<br /> Date of Order:01.01.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> Dated: 1ST DAY OF JANUARY 2009<br /> PRESENT<br /> <br /> <br /> <br /> Sri. S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri. BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> <br /> <br /> <br /> <br /> COMPLAINT NO: 1333 OF 2008<br /> <br /> <br /> Smt. Anjali Deshpande,<br /> No.950/27, II Stage, Rajajinagar,<br /> Bangalore-560 010. Complainant<br /> <br /> V/S<br /> 1. Mr. Pandian,<br /> Branch Manager,<br /> United India Insurance Co. Ltd.,<br /> 6th Block, Rajajinagar,<br /> Bangalore-560 010.<br /> <br /> 2. Syed Nazia Aman, <br /> Manager, E. Mediteck Solutions Ltd.,<br /> S 602, South Block,<br /> Manipal Center, Dickenson road,<br /> Bangalore-560 042. Opposite Parties<br /> <br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> <br /> The complaint was allowed on 31/07/2008 and opposite parties were directed to pay sum of Rs.23,967/- to the complainant within 30 days from the date of the order. The said order was passed on 31/07/2008. The first opposite party United India Insurance Co. Ltd., filed an application for setting aside the order and sought permission to file defense version and contest the matter. The Miscellaneous Petition No.10/2008 was allowed on 19/12/2008. Opposite party No.2 has not appeared and contested the matter. Opposite party No.1 has filed defense version admitting that the opposite party No.1 has issued individual health policy in favour of Smt. Anjali Deshpande, the complainant for a period from 09/08/2007 to 08/08/2008 and liability of the opposite party subject to terms and conditions of the policy. It is also the case of the opposite party No.1 that it has repudiated the claim of the complainant and the complainant is not entitled to any claim on the ground that all psychiatric or psychosomatic disorders are not possible under the policy. Arguments were heard.<br /> 2. The complainant Smt.Anjali Deshpande has filed the complaint stating that she has taken health policy from United India Insurance Co. Ltd.,. This policy is an individual health policy. The policy period was from 9/8/2007 to mid night of 8/8/2008. The sum assured is Rs.2,25,000/-. The husband of the complainant had died. Complainant developed mental disorder and was admitted to Sharavathy Nursing Home, Vijayanagar from 26/2/2008 and discharged on 3/3/2008. The total expenditure incurred was for about Rs.12,325/- inclusive of medicines, treatment and hospital charges. Again the complainant was admitted to Manasa Nursing Home, Shimoga between 5/3/2008 to 14/3/2008. The total expenditure incurred was Rs.9,565/- inclusive of medicines, treatment and hospital charges. The complainant submitted original bills to opposite party No.1 to arrange for reimbursement. The opposite party No.1 forwarded claim form to opposite party No.2 for do the needful on 31/3/2008. The complainant was again admitted to Manasa Nursing Home on 22/4/2008 and discharged on 23/4/2008. The total expenditure incurred was Rs.2,077/-. The original bills were submitted to the opposite parties. The complainant has furnished required details on 17/5/2008 to opposite party No.2. Opposite party No.2 wrote a letter on the pretext that as per the terms of the policy complainant is not entitled to prefer claim for psychiatric disorder. Complainant wrote a letter indicating that the opposite parties have repudiated the claim on the false grounds and she has clearly clarified that she was treated in the hospital as inpatient and was suffering from mental disorder for the past one week of first admission. The discharge summary of both the hospitals and case history justified that complainant was suffering from past one week of the first admission. Therefore, she has filed complaint for redressal and requested to do the needful.<br /> <br /> 3. Affidavit evidence and documents also filed.<br /> 4. The point for consideration is:- <br /> “Whether the repudiation of the claim is justified?” <br /> <br /> REASONS<br /> <br /> 5. The complainant had taken treatment at Sharavathy Nursing Home, Vijayanagar and she has also taken treatment at Manasa Nursing Home, Shimoga. The complainant has produced hospital bills and medical bills. She was inpatient in the hospital. The total amount spent by the complainant towards her treatment was Rs.23,967/-. The opposite parties should have accepted the claim and paid the amount. The repudiation of the claim by the opposite parties is not justified. Consumer Protection Act is enacted to safeguard the better interest of consumers. The Consumer Protection Act is a social legislation. It is a benevolent legislation passed by the Parliament. The service provider cannot deny the claim of the consumer on some technical grounds. The service provider has to take a liberal and broader view in admitting the claim. The complainant who is a widow she had taken health policy after death of her husband and she suffered some mental disorder and taken treatment in the hospital and spent amount and submitted the claim to the opposite parties, but the opposite parties instead of accepting her claim have repudiated the claim without proper and justifiable grounds. The claim of the complainant had been repudiated on the ground that all psychiatric or psychosomatic disorders are not covered or not payable under Clause 2.4 (ii)(ix) of policy conditions. As per the Hospital discharge summary it is nowhere stated by the Hospital that the complainant was suffering from psychiatric or psychosomatic disorders. The complainant had taken treatment for bipolar disorders. Therefore, the repudiation of claim by the opposite party is not justified. The complainant submitted that the opposite parties have taken premium amount again and issued policy even after repudiation of the claim. So, when this is the case the repudiation of the medical claim of the complainant by the opposite party is really not justified. The opposite parties could have allowed the claim and paid the amount spent by the complainant towards her treatment. So, taking into consideration of all the facts and circumstances of the case, documents and the arguments, I am of the opinion that the complaint is liable to be allowed. In the result, I proceed to pass the following:-<br /> ORDER<br /> <br /> 6. The complaint is allowed. The opposite parties jointly and severally are directed to pay a sum of Rs.23,967/- to the complainant(claim amount) within 30 days from the date of this order. In the event of not complying of the order the complainant is entitled to interest at 12% p.a on the claim amount from the date of this order till payment/realization. Complainant is entitled to Rs.2,000/- towards costs of the present proceedings from the opposite parties.<br /> 7. Send the copy of this Order to both the parties free of costs immediately. <br /> <br /> 8. Pronounced in the Open Forum on this 1ST DAY OF JANUARY 2009. <br /> <br /> Order accordingly,<br /> <br /> PRESIDENT<br /> We concur the above findings. <br /> <br /> MEMBER MEMBER <br /> <br /> Rhr., <br /> <br /> <br /> <br />