COMPLAINT FILED ON: 12.04.2010
DISPOSED ON: 31.01.2011
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)
31ST JANUARY 2011
PRESENT :- SRI. B.S. REDDY PRESIDENT
SMT. M. YASHODHAMMA MEMBER
SRI. A. MUNIYAPPA MEMBER
COMPLAINT NO.802/2010
Complainant | M/s. Swastik General & Health Care Services (P) Ltd., Kamadhenu Corner, No.399, II Floor, 1st Main, 1st Stage, 3rd Phase, Manjunatha Nagar, WOC Main Raod, Bangalore-560 010 Rep. by its Authorising Signatory K.B.Jayaram Advocte : K.Surendra Babu V/s. |
OPPOSITE PARTY | M/s. Reliance General Insurance Co. Ltd., No.28, 5th Floor, East Wing, 1st Floor, Richmond Road, Centenary Buildings, M.G.Road, Bangalore-560 001 Rep. by its Branch Manager Advocte : Ravi S. Samprathi |
O R D E R
SMT. M. YASHODHAMMA, MEMBER
The complainant filed this complaint u/s. 12 of the Consumer Protection Act of 1986 seeking direction against the OP (herein after called as O.P) to re-imburse the Medical expenses of Rs.18,476/- along with interest 18% p.a. from the date of accident till payment and pay damages of Rs.10,000/- and cost on the allegations of deficiency in service on the part of the OP.
2. The brief averments made in the complaint are as follows:
Complainant had taken Group Insurance Policy from OP same was valid from 5.03.2009 to 04.03.2010. In the said policy one Ms. Savitha is also included. The serial No. of Savitha is 395 in the said Group Insurance. On 25.01.2010 while walking on the road said Savitha got slipped and fell down and her right leg was injured. Immediately she was shifted to Shobha Hospital, Vijayanagar, Bangalore for treatment. She was admitted to the said hospital on 25.01.2010 and discharged 26.01.2010 she has incurred hospitalization and medical expanses of Rs.18,746/-. The entire original bills and vouchers for re-imbursement of medical expenses were submitted to OP. By its letter dated 05.03.2010 OP has rejected the claim of complainant; Stating “Upon the happening of any event which may give raise to claim under this policy, notice with full particulars shall be sent to the nearest officer of the Company within 7 days from the date of hospitalization. Intimation provided on 05.02.2010 i.e., 11 days after hospitalization. Since there is a delay in intimation, the claim has been repudiate under clause 5.4”. OP has not settled the genuine claim of the complainant, for more than one year. As per the agreement entered into between parties claim shall be processed by OP within 5 working days. Since one year the claim has not been settled by the OP; on some fictitious grounds. Hence complainant felt deficiency in service on the part of the OP. Under the circumstances complainant is advised to file this complaint against OP for the appropriate relief.
3. On registration of the complaint notice is sent to OP. On service of notice OP entered appearance through its counsel but did not contest the case inspite of giving sufficient opportunity. Hence it is taken as version not filed.
4. In order to substantiate the complaint averments, complainant through its authorized Signatory Mr. K.B.Jayaram filed its affidavit evidence and produced copy of the Group Insurance policy issued by OP, Claim form, copy of the letter dated 15.02.2010 some copy of the discharge summary, Hospital bills, prescription, OP did not contest the matter. Heard arguments of the complainant.
5. It is contended by the complaint that complainant had taken Group Insurance Policy bearing No. 1404392812100024 from OP which is valid from 05.03.2009 to 04.03.2010. Under the said Group Insurance Policy the serial No.395 Ms. Savitha is also one of the beneficiary. The copy of the policy produced disclose the members covered with regard to medical expenses incurred due to accidental injury up to the limit of Rs. one lakh. The said Ms. Savitha on 25.01.2010 while walking on the road get slipped and sustained right leg injury. Immedialy she was shifted to Shobha Hospital, Vijayanagar, Bangalore for treatment on 25.01.2010. Ms. Savitha had sustained degloving injury to right leg, right leg got operated; On 25.01.2010 and under went fibula fixation and discharged from hospital on 26.01.2010. Copy of the medical bills and prescription issued by Shobha Hospital, Vijya Nagar, Bangalore produced by the complainant reveals that total medical expenses incurred is Rs.18,476/-. Further the copies of the receipts, copy of the discharge summary issued by Shobha Hospital are produced; the details of the treatment given by Dr. Sanjay are mentioned. On 15.02.2010 complainant submitted all the original bills for re-imbursement to OP but OP rejected the claim on the ground of delay of 11 days after hospitalization in intimating OP.
6. Inspite of entering appearance through advocate OP has failed to contest the matter and failed to produce any documents. We have perused the unchallenged affidavit evidence and documents produced by the complainant. We are satisfied that complainant has sustained injury while walking on the road and medical bills, prescription corroborate the case of the complainant. The policy is valid as on the date of accident. Hence OP is liable to reimburse the medical expanses incurred by the complainant.
In our view as per the principles laid down in
1 (2009) CPJ 427.
Govt. of Rajsthan & others V/s. Ajab Singh & anothers.
Wherein the Hon’ble Rajasthan State Consumer Dispute Redressal Commission observed.
“In case of group insurance scheme claim preferred after expiry of the two years delay in lodging the claim excused – repudiation of claim on ground of delay unjustified – insurer held liable under the policy”.
The observations and principles of the above citation produced by the complainant is aptly applicable to the facts of the case. Though there is a clause of intimating with full particulars within 7 days but on the basis of the above decided case, on the basis of such a clause OP is not justified in repudiating the claim of the complainant.
7. Under these circumstances we are of the considered view that the complainant is entitled for refund of Rs.18,476/- and litigation cost of Rs.1,000/-. Accordingly we proceed to pass the following:
ORDER
The complaint is allowed in part. OP is directed to pay Rs.18,476/- along with litigation cost of Rs.1,000/- to the complainant within four weeks from the date of communication of this order; failing which complainant is entitle to claim interest at the rate of 12% p.a. from 05.03.2010 till the date of payment.
(Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 31ST day of January 2011.)
PRESIDENT
MEMBER MEMBER
gm.
