Karnataka

Kolar

CC/54/2014

Sri. M. Balaraj - Complainant(s)

Versus

M/s. IFFICO-TOKIO General Insurance Co. Ltd., - Opp.Party(s)

B.S.S.Sathya narayana

13 May 2015

ORDER

                Date of Filing: 17/10/2014

Date of Order: 13/05/2015

BEFORE THE KOLAR DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, D.C. OFFICE PREMISES, KOLAR.

 

Dated: 13^th DAY OF MAY 2015

PRESENT

Sri. N.B. KULKARNI, B.Sc., LLB, (Spl.)   …. PRESIDENT

Sri. R. CHOWDAPPA         , B.A., LLB                      …. MEMBER

CONSUMER COMPLAINT NO: 54 OF 2014

Sri.M.Balaraj,

S/o.late Munivenkatappa,

Kumbarahalli Village,

Kasaba Hobli,

Kolar Taluk & District.

 

(Rep. by Sri.B.S.Sathyanarayana

& Ashoka, Advocates)                                       ….  Complainant.

 

- V/s -

The Branch Manager,

M/s. IFFICO-TOKIO General

Insurance Company Limited,

Adithya Building, 2^nd Floor,

S.N.R. Hospital Circle,

Bangarpet Road,

KOLAR-563 101.

 

(Rep. by Sri.B.Kumar & Radha

Kumar, Advocates)                                        …. Opposite Party.

-: ORDER:-

BY SRI. N.B. KULKARNI PRESIDENT

01.   The complainant having applied Under Section 12 of the Consumer Protection Act, 1986 has sought, relief against the opponent for recovery of sum of Rs.50,000/- towards medical expenses including attendant charges, and Rs.25,000/- towards damages and Rs.10,000/- towards deficiency in service together with costs and interest at the rate of 18% per annum from the date of the claim application being 24.01.2014, till realization.

 

02.   The facts in brief:-

The complainant to contend that, he has been working as an Administrative Assistant, Grade-1, at Kolar-Chickballapur Co-operative Milk Producers Societies Union Limited, Main Dairy, National Highway No.4, Huttur Post, Kolar Taluk and District.  And that he has taken a group Medi-shield insurance policy with the opponent through his employer.  And that the policy was to bear No.52284962 with effect from 01.08.2013 till 31.07.2014.

 

a) Further he to contend that on 12.12.2013 he got fever and took treatment at Srinivasa Nursing Home, Kolar, as an out-patient till 16.12.2013 and that in spite of better treatment as the fever could not be subsided, on 17.12.2013 he went to Harish Poly Clinic and Diagnostic Laboratory at Kolar and Dr. K.N.Harish on clinical examination advised him to get admitted in any hospital instantly.  And that accordingly he got admitted at ETCM Hospital, Kolar, on 17.12.2013 itself.  And that on diagnosis it was found that, he was suffering from ENTERIC FEVER.  And that he remained in the hospital till 19.12.2013 and got discharged with advice for follow-up treatment.  And that the medical expenses including charges of attendant came to more than Rs.50,000/-.

 

b) Further he to contend that, he placed the claim on 24.01.2014 with the opponent on the basis of the said policy.  And that surprisingly on 22.03.2014 the opponent repudiated the claim and that on 02.07.2014 he got issued notice.  And that on 05.08.2014 the opponent again repudiated the claim. 

 

c) Thus he to plead that, besides said sum of Rs.50,000/- he was entitled to Rs.25,000/- towards damages, Rs.10,000/- towards deficiency in service.  Thus he has come up with the complaint on hand to seek above setout relief.

 

03.   Along with the complaint the complainant has submitted following nine documents:-

(1) Medical prescription dated: 12.12.2013.

(2) Medical prescription dated: 16.12.2013.

(3) Discharge summary.

(4) To whomsoever it may concern certificate issued by ETCM Hospital, Kolar.

(5) Repudiation letter dated: 22.03.2014.

(6) Legal Notice Dated: 02.07.2014.

(7) Postal receipt.

(8) Postal acknowledgement.

(9) Reply Notice dated: 05.08.2014.

 

04.   In response to the notice issued the opponent has put in appearance through the said learned counsel and has also submitted written version registering claim of the complainant in toto.  Inter-alia, he to contend that, the complainant was given treatment conservatively and was discharged on a stable condition.  And that there could be no need for hospitalize as OPD treatment was enough.  Further it is contended that it is the standard procedure under the insurance law that policy wordings and terms and coverage shall be guiding norms while scrutinizing any claim.  And that for hospitalization besides the necessity the treatment and the procedure should be a requirement of specialized infrastructure facilities available in the hospital. 

 

(a) Further it is contended that, in spite of queries and reminders dated: 28.01.2014, 12.02.2014, 27.02.2014, 03.03.2014, 17.03.2014 and 19.03.2014, the complainant failed to submit the required documents, so contending dismissal of the complaint has been sought.

 

05.   On 20.12.2014 the complainant submitted his affidavit evidence, as well a list with screen shots of the e-mail correspondence made with the OP with a further request for re-consideration of his claim.

 

(a) On 23.04.2015 the opponent has submitted affidavit evidence through Mr.Sanjay Seth, an Executive – Vice - President.

 

(b) On 06.05.2015 the learned counsel appearing for the complainant with a list has submitted following eleven documents:-

 

(1) Diagnostic Report dated: 17.12.2013 with result (Xerox).

(2) Medical Bills 11 in No’s (originals)

(3) Medical prescriptions 08 in No’s (originals)

(4) To whomsoever it may concern dated: 30.12.2013 (original)

(5) Discharge summons (original)

(6) To whomsoever it may concern dated: 04.04.2014 (original)

(7) Repudiation letter dated: 22.03.2014 (original)

(8) Legal Notice dated: 02.07.2014 (office copy)

(9) Postal receipt and acknowledgment (original).

(10) Reply Notice dated: 05.08.2014 (original).

(11) Insurance Policy copy (Xerox).

 

06.   The learned counsel for both sides, have submitted their respective written arguments.  On 11.05.2015 heard the oral arguments as advanced by the learned counsel appearing for both sides.

 

07.   Therefore the points that do arise for our consideration in this case are:-

(A) Whether the opponent is guilty of deficiency in service as contended by the complainant?

 

(B) If so, to what relief the complainant is entitled to?

 

(C) What order?

 

08.   Findings of this District Forum on the said points for the following reasons are:-

POINT (A):       In the Affirmative.

 

POINT (B): The complainant is entitled to compensation of Rs.17,000/- for being paid by the opponent within a month from the date of communication of this order to the complainant failing which, the complainant is further entitled to interest for this sum at the rate of 9% per annum from 24.01.2014 being the date of claim application, till realization.

POINT (C):   As per final order.

 

REASONS

POINT (A) & (B):-

09.   To avoid the repetition in reasonings and as these points do warrant a common course of discussion, the same are taken up for consideration at a time. 

 

(a) It is a fact that the said Group Medishield Insurance Policy issued by the opponent to this complainant among others was to bear the policy No.52284962.  And also it is a fact that this policy was in vogue with effect from 01.08.2013 to 31.07.2014.  It is also a fact that the complainant had illness of “ENTERIC FEVER” (Typhoid).  In order to repudiate the claim the only contention urged by the OP is that, for the said ailment there could be treatment for the complainant as an out-patient in as much as the condition never warranted that he should be in-patient as contended. 

 

10.   Such a contention on the part of the opponent is certainly to avoid the legal liability.  It cannot be denied that the complainant caught fever on 12.12.2013 and till 16.12.2013 he got treatment as an out-patient only.  As the fever did not subside he was constrained to approach Dr. Harish who on clinical examination cautioned the complainant to get admitted in any one of the hospitals instantly.  Therefore under responsible medical advice he got admitted in the said hospital.  So the opponent cannot even afford to plead that such ailment as suffered by the complainant ought to have been treated only as out-patient.  During the hearing dated: 06.05.2015 the complainant has submitted eleven documents, of which many are impertinent.  The learned counsel for the opponent drew our attention to the cash bill issued by M/s. Omkar Medicals dated: 17.12.2013 disclosing an amount of Rs.7,858/- towards purchase of the medicines therein.  When on 17.12.2013 itself this complainant got admitted in the said renowned hospital seemingly there was no need for purchasing of the said medicines as covered by the said cash bill issued by M/s. Omkar Medicals.  So by way of caution, we place reliance on document dated: 30.12.2013 as issued by ETCM Hospital at Kolar being the very renowned hospital.  This documents shows that, the complainant paid money mentioned under so many heads that came to total sum of Rs.15,537/-.  For two days of stay on the part of the complainant in this hospital as an in-patient, he must have spent on the accompanied attendant some money which can be easily guessed up to Rs.1,500/-.  Thus the total compensation would come to Rs.17,037/- and by removing the fraction we confine this compensation to sum of Rs.17,000/- being the round figure for which the complainant is entitled to.

 

POINT (C):-

11.   We proceed to pass the following:-

 

ORDER

01.   For foregoing reasons this complaint stands allowed with costs of Rs.1,000/- against the opponent as hereunder,

 

02.   The opponent shall pay compensation of Rs.17,000/- to this complainant within a month from the date of communication of this order to the complainant failing which, the complainant is further entitled to interest for this sum at the rate of 9% per annum from 24.01.2014 being the date of claim application, till realization.

 

03.   Send a copy of this order to both parties free of costs.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Forum on this, the 13^th DAY OF MAY 2015)

 

      MEMBER                             PRESIDENT