Date of Filing:13.08.2007<br /> Date of Order: 31.12.2007<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> Dated: 31ST DAY OF DECEMBER 2007<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 /> COMPLAINT NO: 1710 OF 2007 <br /> <br /> Dr. S.N.Meera,<br /> W/o S. Krishnamurthy,<br /> R/at No.55, 16th Cross,<br /> Betn 13th & 14th Main,<br /> Malleswaram West,<br /> Bangalore-560055. Complainant<br /> <br /> V/S<br /> 1. M/s Oriental Insurance Company, <br /> DO 45, Shankar House, III Floor,<br /> No.1, RMV Extension, Mekri Circle,<br /> Bangalore-560080<br /> <br /> 2. Medi Assist India Private Ltd.,<br /> No.49, “Shilpa Vidya” Buildings,<br /> 1st Main, Sarakki Industrial Layout,<br /> III Phase, J.P. Nagar, <br /> Bangalore-560078. pposite Parties<br /> <br /> ORDER<br /> <br /> This complaint is filed U/Sec.12 of the Consumer Protection Act, 1986 claiming Rs.18,652/- with interest and costs. <br /> The facts of the case are that, complainant took medical insurance for herself and family for period from 22/7/2005 to 21/7/2006 by paying premium amount of Rs.3,700/- with policy No.10340 with opposite party No.1. Complainant was having the Menorrhagia commencing from 27/1/2006 and had consultation with Dr: Gunasheeela at Gunasheela Surgical and Maternity Hospital, Bangalore on 16/2/2006. Dr: Sulochana Gunasheela advised the complainant to undergo hysteroscopy plus aurrettage plus Thermo choice. It became a necessity for the complainant to undergo thermo choice at Gunasheela Surgical and Maternity Hospital. Complainant was admitted to the Hospital on 18/5/2006 and she was discharged on the same day after undergoing thermo choice. The complainant submitted her claim with second opposite party enclosing all the original bills and copy of the policy. The total amount of the bill was Rs.18,652/-. Since there was no communication from the opposite party on being contacted it was informed that the claim under policy will not be paid. Hence, the complaint. <br /> 2. Notice was served to opposite parties. They have appeared through counsel and submitted defense version stating that, as per the conditions of medi-claim policy, the policy does not cover the risk of any disease resulting in treatment taken for which hospitalization is less than 24 hours and treatment taken under day care procedure as per exclusion clause 2.3 of the policy terms and conditions. It is submitted that the insured has insurance policy since 22/7/2005 for a sum assured of Rs.70,000/- with the opposite party No.1 Oriental Insurance Company Limited. Complainant had submitted the medical records pertaining to treatment for settlement of the medi-claim. As treatment was day care procedure and policy covers only inpatient investigations with minimum stay of 24 hours in the hospital this claim not fulfilling these conditions the claim was repudiated. Opposite party No.2 submits that there is no deficiency in service as alleged by the complainant. <br /> 3. Both the parties have filed affidavit evidence. Arguments are heard. <br /> 4. The points for consideration are:-<br /> 1. Whether there was deficiency of service on the <br /> part of the opposite parties?<br /> 2. Whether the complainant is entitled for the <br /> insurance claim of Rs.18,652/-? <br /> <br /> REASONS<br /> 5. It is an admitted case of the parties that, the complainant Dr: S.N. Meera has taken medical insurance policy from the Oriental Insurance Company Limited. The sum assured was Rs.70,000/-. The policy period was between 22/7/2005 to 21/7/2006. It is also admitted case of the parties that, complainant consulted Dr: Gunasheela at Gunasheela Surgical and Maternity Hospital, Bangalore on 16/2/2006 and as per the Doctor’s advise the complainant underwent thermo choice at Gunasheela Surgical and Maternity Hospital on 18/3/2006 and she was discharged on the same day. So as per the hospital records the treatment was within the policy period. The complainant has produced hospital bills of Rs.18,652/-. The complainant has submitted claim petition on 20/3/2007. Since the opposite parties did not settle the claim and there was no communication from the opposite parties. The complainant has stated that, on being contacted it was informed by the opposite party No.2 that the claim under policy will not be paid. Therefore, the complainant was forced to approach this Forum for getting relief. The only objection of the opposite party in not paying the claim amount is that the policy does not cover the risk of any disease or conditions resulting in treatment taken for which hospitalization is less than 24 hours and treatment taken under day care procedure as per exclusion clause 2.3 of the policy terms and conditions. To this objection the learned counsel for the complainant brought to our notice clause 3(b) of the policy wherein there is an exception for the patient to be in the hospital for minimum period of 24 hours, if the treatment is such it does not require hospitalization by virtue of technological advance in treatment. So by reading clause 3(b) it is very clear that, due to technological advances hospitalization is required for less than 24 hours. In that case also the insurance company cannot deny the claim stating that the complainant was discharged from hospital within less than 24 hours. Therefore, the opposite party cannot rely upon the exclusion clause in this case. As per the exception to the policy conditions even if the patient was discharged within 24 hours, in that case also the insurance claim must be accepted and amount shall have to be paid to the beneficiary. The Consumer Protection Act, is enacted to provide for better protection of the interest of consumers. The interpretation of the rule should be in favour of the consumers. In this case, when there is a clear cut exception to the rule by virtue of technological advancement in treatment if the patient is discharged within 24 hours in that case also the insurance claim must be accepted and the amount spent by the parties has to be paid. The opposite parties have taken untenable and unacceptable defense. There is absolutely no merit in the defense taken by the opposite parties. Therefore, there is definitely a deficiency of service on the part of the opposite parties. The complainant is entitled for the claim amount with interest and costs. The opposite parties instead of accepting the claim refused to pay the amount. Therefore, the opposite parties shall be asked to pay the interest on the claim amount for the delay caused in settling the claim. In the result, we proceed to pass the following:- <br /> ORDER<br /> <br /> 6. The complaint is allowed. The opposite parties are directed to pay Rs.18,652/- to the complainant with interest at 12% p.a from 15/11/2006 (the date of submission of claim) till the payment. <br /> 7. The complainant is also entitled for the costs of Rs.5,000/- from the opposite parties.<br /> <br /> 8. Send the copy of this Order to both the parties free of costs immediately. <br /> <br /> 9. Pronounced in the Open Forum on this 31ST DAY OF DECEMBER 2007.<br /> Order accordingly,<br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br />