IN THE DISTRICT CONSUMERS’ DISPUTES REDRESSAL FORUM AT MYSORE<br /> <br /> PRESENT: 1. Shri.D.Krishnappa<br /> B.A., L.L.B - President<br /> <br /> <br /> 2. G.V.Balasubramanya<br /> B.E., LL.M - Member<br /> <br /> CC 200/06 DATED 20-12-2006<br /> <br /> Complainant Sri N.Prasad, s/o N.Appaji Rao, No.498, “Neelanjana”, 3rd Stage, ‘B’ Block, 11th Cross, Vijayanagar, Mysore.<br /> (By Sri.R.G.Narasimha Iyengar, Advocate)<br /> Vs. <br /> Opposite Parties 1. M/s United India Insurance Co., Ltd., No.1260, 2nd Floor, Vinoba Road, Shivarampet, Mysore. <br /> 2. M/s Family Health Plan Ltd., No.1, 2nd Floor, 11th Main, Vasanthnagar, Bangalore. <br /> (By Sri.J.S.K., Advocate)<br /> <br /> Nature of complaint : Deficiency in service<br /> Date of filing of complaint : 14.07.2006<br /> Date of appearance of O.P. : 21.08.2006<br /> Date of order : 20.12.2006<br /> Duration of Proceeding : 4 Months<br /> <br /> <br /> <br /> <br /> <br /> PRESIDENT <br /> <br /> MEMBER<br /> <br /> <br /> <br /> <br /> Sri.D.Krishnappa,<br /> President<br /> <br /> 1. The Complainant has presented this Complaint under section 12 of the Consumer Protection Act, 1986 against the opponents.<br /> <br /> 2. The allegations of the Complainant in brief are:- that himself and his wife had Individual Mediclaim Policy from the 1st opponent, which are valid till the midnight of 30.03.2007, wherein the 1st opponent has agreed to meet all the expenses of hospitalization of himself and his wife and there are two types of source available for them for reimbursement i.e., cashless hospitalization and reimbursement of the expenditure incurred after the treatment is over. Out of those two sources, he opted cashless hospitalization and after admitting his wife to hospital, intimated the 2nd opponent seeking the relief. That his wife was admitted to hospital on 12.06.2006 and was discharged on 16.06.2006. Immediately he approached the 1st opponent to reimburse the medical expenditure amounting to Rs.8,968/- but 2nd opponent refused to provide the benefit of cashless hospitalization and directed him to approach the 1st opponent. Therefore, the 1st opponent is liable to reimburse the amount spent by him under Mediclaim Policy Scheme and therefore, he has prayed for reimbursement of Rs.8,968/- with interest at 18% p.a., Rs.2,000/- towards mental agony and harassment and cost of this case at Rs.1,000/-.<br /> <br /> 3. The 2nd opponent who is served with notice of this Complaint has remained absent and is placed exparte. The 1st opponent has filed his version admitting to have issued Mediclaim Policy covering the risk of the Complainant and his wife and its liability in accordance with the terms and conditions of the Policy. It is further contended that they have tied up with the 2nd opponent to take care of all Mediclaim Polices. It is further admitted two source of facilities that the Complainant could avail as stated by the Complainant and stated that the 2nd opponent from whom cashless hospitalization was sought denied that facility to the Complainant’s wife on the ground the wife of the Complainant had a past history of certain disease and adviced the Complainant to get his claim settled from the 1st opponent after completion of treatment. It is further contended that the Complainant after completion of treatment did not furnish any bills to it for reimbursement and it has not repudiated the claim at any point of time. Therefore, there is no cause of action to file this Complaint. The Complainant has directly approached this Forum without giving any chance to it to settle his claim and stated that it is always ready and willing to settle the claim of the complainant on producing the bills and therefore prayed for dismissal of the complaint. Further contended that there is no deficiency in their service.<br /> <br /> 4. The complainant in proof of the allegations filed his affidavit evidence certain documents and hospital bills. The Divisional Manager of the 1st opponent also filed his affidavit evidence in support of his contentions. Heard the counsel for both the parties and perused the records.<br /> <br /> 5. On the above contentions, following points for determination arise.<br /> <br /> 1. Whether the Complainant proves that the opponents have caused deficiency in their service in not meeting the medical expenditure of the complainant’s wife?<br /> <br /> 2. Whether the Complainant is entitled for relief as sought for?<br /> <br /> 3. What order?<br /> <br /> 6. Our findings are as under:-<br /> Point no.1 and 2 : In the negative.<br /> Point no.3 : See the final order.<br /> <br /> REASONS<br /> <br /> 7. Points no. 1 & 2:- The 1st opponent has admitted the claim of the Complainant that himself and his wife availed Mediclaim Policy from the 1st opponent and the complainant had two source of availing the facility. One is cashless hospitalization and another reimbursement of the amount spent by him for the treatment. Therefore, we need not go the details of terms and conditions of the policy that the complainant availed. Thus the question remains is whether the complainant availed those facilities.<br /> <br /> 8. The complainant in his complaint as well as in the affidavit filed by him, no doubt has stated when he got his wife admitted to hospital, he intimated the 2nd Opposite party seeking relief from it. That means, the complainant intended to avail cashless hospitalization, which means the complainant without spending any money for admission, treatment and purchase of medicines, requested the 2nd opponent to extend cashless facility. But, the 2nd opponent through it’s letter dated 15.06.2006 addressed to Bassappa Memorial Hospital, Mysore denied cashless hospital facility to the wife of the complainant, contending that insured’s coverage terms and conditions, do not permit them to extend the cashless facility and declined to issue authorization. It is further seen from the copy of the letter addressed by the 2nd opponent to the 1st opponent, 2nd opponent refused to extend cashless facility to the complainant on the ground that their medical team opined that there was a possibility of the present ailment of the wife of the complainant being a pre-existing disease for the reasons stated in the said letter. With this cashless facility to which the complainant opted was not given. Therefore the next course opened to the complainant is after the treatment to produce all the bills with a claim to the 1st opponent and get the medical expenditure reimbursed.<br /> <br /> 9. The Complainant in his complaint has not challenged the action of the 2nd opponent in denying the facility of cashless hospitalization as illegal or unsustainable and that dead to deficiency of service. It could be seen, the complainant nowhere has alleged that denial of the cashless hospitalization facility by the 2nd opponent is improper or the ground on which his claim is denied is either arbitrary or illegal. The claimant, therefore has not assailed the denial of the 2nd opponent. Thereby he has given up his claim for cashless hospitalization but has come up with this complaint with main allegation against the 1st opponent in not reimbursing his medical expenditure.<br /> <br /> 10. As we have already stated above, the complainant had 2 source of availing benefit of Mediclaim facility. One being cashless facility, he did not pursue it nor questioned it. Therefore, if he is found not serious about the denying cashless facility. Then the 2nd option open to him is to make a claim with the 1st opponent after completion of treatment by producing all the documents in support of his claim. That what the conditions of the policy also speak about. Even in the letter addressed by the 2nd opponent to the 1st opponent, the 2nd opponent has categorically stated that denial of cashless hospitalization to the complainant does not mean that the complainant cannot seek reimbursement of medical expenditure from the 1st opponent. Therefore, under these circumstances, what the complainant could have done is to make a claim with the 1st opponent after all the treatment to his wife is over by producing all the supporting documents to get the expenditure reimbursed. Thus we shall now see, whether the complainant has done the part of his job by doing so to enable the 1st opponent to reimburse the expenditure incurred by the complainant.<br /> <br /> 11. The 1st opponent in his version and the affidavit filed by it, have categorically stated that the 2nd opponent advised the complainant to get his claim reimbursement after completion of treatment and further contended that the complainant after treatment did not furnish the bills to it for reimbursement that they have not repudiated the claim at any point of time. That there is no cause of action for this complaint and it is even now ready to reimburse the claim of the complainant on furnishing the documents, bills etc., with the claim application. This contention of the opponent are not contradicted by the complainant and it is not the case of the complainant that he put forth a claim before the 1st opponent for reimbursement of the expenditure after completion of the treatment with supporting documents. Therefore, when the complainant did not approach the 1st opponent for reimbursement that then complainant cannot complain of denial or deficiency against the 1st opponent. Admittedly when the complainant did not question the act of 2nd opponent, but attributed deficiency of service against 1st opponent. Deficiency could have been seen in the event of the 1st opponent denying the claim of the complainant for reimbursement of his if he had made a claim by producing all necessary supporting documents. Therefore, in the absence of such an action from the side of the complainant, the complainant cannot complain any deficiency in service and this Forum cannot accede to the plea of the complainant. The complainant in his complaint has not even mentioned as to when the cause of action arose for filing this complaint. Therefore, considering these facts and the contentions taken by the opponent before this Forum, we are inclined to hold that the complainant having not made a claim for reimbursement under the terms of the policy with the 1st opponent he cannot contend that 1st opponent has caused deficient service. The 1st opponent has given an unvivokable offer to the complainant to make a claim with it for reimbursement then they are always ready to settle his claim on his producing the bills. With this we hold that we are not inclined to accept the allegation of the complainant that 1st opponent has caused deficient service. Therefore the complaint is liable to be dismissed. With the result, we answer the above point in the negative and like to observe here, that the complainant can make a claim with the 1st opponent by producing all the necessary bills to enable it to settle his claim. The 1st opponent without prejudice to the action initiated by the complainant shall settle his claim, without much delay. Thus we pass the following order.<br /> <br /> ORDER<br /> <br /> 1. The Complaint is dismissed.<br /> 2. Parties to bear their own costs.<br /> 3. Give a copy of this order to each party according to Rules.<br /> <br /> (Dictated to the Stenographer, transcribed by her, transcript revised by us and then pronounced in the open Forum on this the day 20th December 2006)<br /> <br /> <br /> <br /> <br /> <br /> (D.Krishnappa) <br /> President <br /> (G.V.Balasubramanya)<br /> Member<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />