Complaint filed on: 19.03.2015
Complaint Disposed on:04.02.2017
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AT CHICKMAGALUR.
COMPLAINT NO.70/2015
DATED THIS THE 4th DAY OF FEBRUARY 2017
:PRESENT:
HON’BLE SRI RAVISHANKAR, B.A.L, LL.B., - PRESIDENT
HON’BLE SMT B.U.GEETHA, M. COM., LL.B., -MEMBER
HON’BLE SMT H. MANJULA, B.A.L., LL.B., - MEMBER
COMPLAINANT:
K.C Rathan S/o Chandre Gowda,
A/a 35 years,R/o Koralagadde,
Kundur post, Mudigere Taluk,
Presently R/at Rameshwara Nagar,
Chikmagalur City.
(By Sri/Smt. S.H. Mahesh Kumar, Advocate)
V/s
OPPONENT:
1. M/s.TATA AIG General Insurance
Co., Ltd, Peninsula Business Park
Tower ‘A’, 15th Floor, Ganapath Rao
Kadam, Lower Parel, Mumbai-400013.
2. The Manager, Axis Bank Ltd,
Chikmagalur Branch, Basavanahalli
Main Road, Chikmagalur City.
(OP-1 By Sri/Smt. H.N. Ravikumar, Advocate)
(OP-2 By Sri/Smt. Halekote A.Thejaswi, Advocate)
By Hon’ble President Sri. Ravishankar,
:O R D E R:
The complainant filed this complaint U/s 12 of the Consumer Protection Act 1986 against OP Nos. 1 & 2 alleging deficiency in service in not settling the medical claim towards the medical treatment. Hence, prays for direction against OP Nos. 1 & 2 to settle the claim to the tune of Rs.2,36,865/- with interest at 18% p.a. along with compensation of Rs.50,000/- for deficiency in service.
2. The brief facts of the complaint is that:
The complainant had obtained Medi-Prime policy from Op no.1 through Op no.2 bank and paid a premium of Rs.8,091/- towards the policy, the Op no.1 had issued a policy under Family Floater plan which commenced from 12.11.2013 to 11.11.2014, the said policy also renewed subsequently on 12.11.2014 and is valid up to 11.11.2015, at the time of renewal also complainant paid a premium of Rs.8,091/- and Op no.1 had issued a policy bearing no.020027895200-020027895201, such being the case the complainant due to some illness had hospitalized to the Suguna Hospital at Bangalore which was notified hospital of the Op no.1 company. On admission of the complainant the doctors have advised to undergo for an immediate operation and also demanded to deposit an amount to the hospital, at that time the complainant gave the medi prime card which was issued by Op no.1 to the hospital authorities for providing of cashless benefits.
Accordingly, the complainant on 24.12.2014 under went Thyroidectomy and after the recovery he discharged from hospital. After the discharge the complainant informed by the hospital that Op has not honored the cashless benefit and demanded for settlement of the Medical expenses, the complainant had paid an amount of Rs.1,86,569/- towards medical expenses at Suguna hospital, apart from the said expenses the complainant also spend nearly Rs.50,000/- towards the attendant charges, in total the complainant had spend Rs.2,36,569/- towards the treatment.
The complainant after discharge contacted the Op and given a complaint with respect to the non-settlement of the claim of the hospital, but the Ops have not responded properly, subsequently, the complainant issued legal notice dated 16.01.2015 and called upon the Op no.1 and 2 to settle the claim, even in spite of receipt of the legal notice Op no.1 and 2 have not settled the claim, instead of settlement the 2nd Op replied untenably and shifted the burden on Op no.1 company, thus the Op no.1 and 2 have rendered a deficiency in service in not settling the genuine medi claim of the complainant. Hence, prays for direction against OP Nos. 1 & 2 to settle the claim along with compensation for deficiency in service as prayed above.
3. After service of notice the OP Nos. 1 & 2 appeared through their counsels and filed the versions.
The OP No.1 in his version has contended that the complaint is not maintainable in law or on facts and complaint of the complainant is premature one, hence, is liable to be dismissed.
The complainant had obtained hospitalization benefit policy from this Op, covering the risk from 12.11.2014 to 11.11.2015 and same is governed by terms and conditions of the policy, this Op no.1 had tie up with Op no.2 in order to facilitate the customers for quick and speedy service.
The complainant had not made any claim or demand in writing to this Op for reimbursement of the hospitalization charges by furnishing the relevant documents in spite of rejection of cashless access benefit, he also replied to the legal notice dated 24.03.2015 and clearly mentioned the reason for denial of cashless access to the complainant. The complainant after rejection of the cashless access benefit he is at liberty to claim for hospitalization expenses subject to terms and conditions of the policy, but the complainant not at all claimed in writing to this Op. Hence, complaint is premature one and prays for dismissal of the complaint.
Op no.1 further contended that they do not know that the complainant had spend Rs.2,36,569/- towards the medical expenses and also do not know that he had no past history of Thyroidectomy at the time of availing medi-prime policy from this Op.
Op further contended that after receipt of the cashless request from Suguna hospital for retrosternal goiter with compression trachea and the said request was not granted as the hospital authority have not submitted the supporting documents along with the request as prima-facie and ailment appeared to fall under 2 year waiting period clause as per the exclusions of the policy mentioned in exclusions 3 of the policy. Hence, the cashless benefit was rejected, there is no any deficiency in service on the part of this Op in rejecting the cashless claim of the complainant and also not liable to pay any compensation and hence, prays for dismissal of the complaint.
The Op no.2 in his version has contended that the complainant is a customer to this Op bank, but they have not made any compulsion to take the policy from Op no.1 to the complainant. The complainant had taken the policy from Op no.1 voluntarily and there is no any business of insurance is carried out from this Op. The claim made in the complaint is only against Op no.1 and with respect to the policy issued by Op no.1. The grievance if any related to the same has to be settled by Op no.1 not by this Op bank. The notice issued by complainant was suitably replied, stating the same facts, there is no any deficiency in service on the part of this Op with respect to the bank transactions and they are not liable to pay any claim made by complainant and prays for dismissal of the complaint.
4. The complainant filed affidavit and marked the documents as Ex.P1 to P8 and Op no.1 and 2 also filed affidavit and marked the documents as Ex.R.1 to R.4.
5. Heard the arguments:
6. In the proceedings, the following points do arise for our consideration and decision:
- Whether there is deficiency in service on the part of OPs.
- Whether complainant entitled for any relief & what Order?
7. Our findings on the above points are as follows:-
- Point No.1: Affirmative.
- Point No.2: As per Order below.
: R E A S O N S :
POINT NOs. 1 & 2:
8. The case of the complainant is that, he had obtained hospitalization benefit policy from Op vide Policy no. 020027895200-020027895201 since 2013, the said policy was renewed on 12.11.2014 and renewed by the Op to the further up to 11.11.2015, during the policy is in force the complainant hospitalized at Suguna hospital for the surgery called Thyroidectomy, accordingly on 24.12.2014 he under went to surgery at Suguna hospital and discharged subsequently, during his hospitalization the complainant had spent nearly Rs.1,86,569/- towards surgery and another Rs.50,000/- for other expenses towards attendant and incidental charges, in total he spent nearly Rs.2,36,569/-
But the complainant alleges that at the time of admission the Ops have rejected the cashless access benefit, having no option complainant had paid the medical expenses and issued a legal notice for non-settlement of the claim under cashless benefit, even after receipt of the legal notice Op no.1 and 2 have not settled the claim, hence, alleges deficiency in service.
On contrary Op no.1 being a insurer had taken a contention that after the receipt of the cashless request from Suguna Hospital, they have rejected the claim as per the exclusion 3 of the policy terms and conditions as the said ailment falls under the 2 years waiting period clause, hence, the claim was rejected, but the complainant had not made any claim in writing to this Op for reimbursement of the medical expenses, hence, it is premature complaint and submits no deficiency in service on their part.
The Op no.2 has contended that they are only a banker to the complainant and any claim made by complainant as per the policy is only between the complainant and the Op no.1 and submits no deficiency in service on their part.
The complainant has produced policy marked as Ex.P.1, medical bills marked as Ex.P.2, Inpatient bills marked as Ex.P.3, denial of cashless service marked as Ex.P.4, discharge summary marked as Ex.P.5, legal notice issued to Op no.1 and 2 marked as Ex.P.6 and reply to the said legal notice marked as Ex.P.8. On going through the discharge summary i.e., Ex.P.5, we noticed that the complainant had hospitalized on 20.12.2014 with a history of complainant was suffered from breathing problem since 3 months and the said problem increased since 3 days and hospital have revealed that the complainant is suffering from retrosternal goiter and admitted for further management, subsequently during hospitalization he under went Thyroidectomy under general anesthesia, subsequently discharged on 28.12.2014. It is admitted that the cashless access benefit was rejected as per the Ex.P.4. The Op have rejected the cashless benefit to the complainant for the reason that it comes under the exclusion clause under 2 years waiting period, subsequently the complainant paid the entire medical bills and issued a legal notice to Op no.1 and 2, but we observed that after issuance of the legal notice Op no.1 being the insurer have not called the complainant for settlement of the claim even we observed Op no.1 have not offered to settle the claim even after filing this complaint.
The Op had produced copy of the policy issued to the complainant is marked as Ex.R.3 and contended that the said ailment comes under the waiting period of 2 years and submits the complainant is not entitled to get any benefit under the policy. On going through the exclusion clause we noticed that there is no inception of said ailment i.e., Thyroidectomy under 2 years waiting period and the said ailment is also not pre-existed and we also observed that the policy obtained by complainant in the year 2013 itself, which is renewed subsequently such being the case we found there is no reason on the part of Op no.2 reject to the claim of the complainant. We are of the opinion that the rejection of the cashless benefit to the complainant is itself is a deficiency in service on the part of Op no.1 and we also considered that the Op no.1 rendered a deficiency in service in not settling the claim even after filing the complaint, as such the Op no.1 being insurer is liable to settle the eligible claim of the complainant as per the policy term and conditions, Op no.1 being insurer is also liable to pay compensation of Rs.10,000/- for non-settlement of genuine medical claim of the complainant. The complaint against Op no.2 is liable to be dismissed as because the claim made by complainant is only as per the terms and conditions of the policy which is issued by Op no.1, we found there is no any deficiency in service on the part of Op no.2 with respect to the transaction between the complainant and Op no.1, as such the complaint is dismissed against Op no.2. Accordingly, we answer the point no.1 and 2 in the Affirmative and proceed to pass the following:-
: O R D E R :
- The complaint is partly allowed.
- The OP No.1 is directed to pay eligible claim to the complainant under policy No. 020027895200-020027895201 along with compensation of Rs.10,000/- towards deficiency in service and litigation expenses of Rs.2,000/- to the complainant.
- The OP No.1 is further directed to comply the above order within 30 days from the date of receipt/knowledge of the order, failing which the payable amount shall carry interest @ 9% P.A. till realization.
- The complaint against Op no.2 is dismissed.
- Send free copies of this order to both the parties.
(Dictated to the Stenographer transcribed typed by him, transcript corrected by me and then pronounced in Open Court on this the 4th day of February 2017).
(RAVISHANKAR)
President
(B.U.GEETHA) (H. MANJULA)
Member Member
ANNEXURES
Documents produced on behalf of the complainant:
Ex. P1 - Policy with schedule issued by Op
Ex.P2 - Entire medical bills issued by suguna hospital
Ex.P3 - Inpatient bills
Ex.P4 - Denial letter of cashless service dt:23.12.14
Ex.P5 - Discharge summary
Ex.P6 - Office copy of the legal notice
Ex.P7 - Postal ack. Due
Ex.P8 - Reply to the legal notice
Documents produced on behalf of the OPs:
Ex. R1 - Authorization letter
Ex.R2 - Reply to the legal notice dt:24.03.15
Ex.R3 - Policy schedule with terms and conditions
Ex.R4 - Denial of cashless service
Dated:04.02.2017 President
District Consumer Forum,
Chikmagalur.
