| Complaint Case No. CC/527/2020 | | ( Date of Filing : 17 Aug 2020 ) |
| | | | 1. Mr. G. Shankar Prasad | | Aged about 57 Years, S/o Late Ganesh Ram,R/at No.60/2,5th Cross Road,Srirampuram, Bengaluru-560021 |
| ...........Complainant(s) | |
| Versus | | 1. M/s. Star Health and Allied Insurance Company Limited | | No.1,New Tank Street, Valluvar kottam High Road, Nungambakkam,Chennai-600034(Head Office)Rep by its Authorised Representative | | 2. M/s. Star Health and Allied Insurance Company Limited | | Having Branch Office at Indira Arcade,No.81,1st Floor,Dr.Rajkumar Road,Prakashnagar,3rd Stage, Rajajinagar, Bengaluru-560021. Rep by its Authorised Representative |
| ............Opp.Party(s) |
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| Final Order / Judgement | Complaint Filed on:14.08.2020 | Disposed on:24.02.2022 |
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN) DATED 24th DAY OF FEBRUARY 2022 PRESENT:- SRI.K.S.BILAGI | : | PRESIDENT | SMT.RENUKADEVI DESHPANDE | : | MEMBER |
Complainant/s | V/s | Opposite party/s | Mr.G.Shankar Prasad, aged about 57 years, S/o Late Ganesh Ram, R/at No.60/2, 5th Cross Road, Srirampuram, Bangalore-560021. Sri Akash R.Rao, Adv. | | 1. M/s Star Health and Allied Insurance Company Limited., No.1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 (Head Office), represented by its Authorized representative. ABSENT 2. M/s Star Health and Allied Insurance Company Limited, having branch office at Indira Arcade, No.81, 1st Floor, Dr.Rajkumar Road, Prakashnagar, 3rd Stage, Rajajinagar, Bangalore-560021. Represented by its Authorized representative. EXPARTE |
ORDER SRI.K.S.BILAGI, PRESIDENT
1. The complaint has been filed under Section 35 of C.P.Act (hereinafter referred as an Act) against the OP for the following reliefs against the OP:- (a) Reimburse the amount of Rs.38,961/- which was incurred as medical expenses by the complainant as stated above. (b) pay a compensation of Rs.5,00,000/- for causing deficiency of service and resorting to unfair trade practice. (c) Award the cost of these proceedings and (d) Grant such other relief/s that this Hon’ble Form deems fit in the interest of justice and equity. 2. The case set up by the complainant in brief is as under:- The complainant took the policy from the OPs for Rs.6,25,000/- for the period from 11.04.2019 to 10.04.2020 by paying premium of Rs.33,760/-. 3. The complainant got admitted her son Nishanth.S in M/s Columbia Asia Referral Hospital, Yeshwanthpura, Bengaluru for treatment. On completion of the treatment, her son was discharged on 09.10.2019. The complainant struggled lot for payment of Rs.38,961/- as OP No.1 repudiated cashless facility of the complainant. 4. Subsequently, the complainant had submitted claim petition for Rs.38,961/-. But, OPs repudiated the claim. Hence, this complaint. The illegal repudiation of the claim of the complainant amounts to deficiency of service. 5. In response to the notice, both OPs remained absent and OP No.2 has been exparte. On 09.12.2020 both OPs appeared and took time for settlement. But, entire matter is settle nor version is filed. 6. The complainant has files her affidavit evidence and relies on 16 documents. Heard the arguments of the advocate for complainant only. Perused the records. 7. The following points arise for our consideration:- - Whether the complainant proves deficiency of service on the part of OPs?
- Whether the complainant is entitled to relief mentioned in the complaint?
- What order?
- Our answers to the above points are as under:
Point No.1: In the affirmative Point No.2: Affirmative in part Point No.3: As per final orders REASONS - Nos.1 and 2: The complainant in support of her contention, places reliance on her affidavit evidence and documents. The case set up by the complainant remains un-challenged. However, on 06.07.2021 a memo came to be filed on behalf of OPs with a statement that final admissible amount is Rs.22,251/-. Under such circumstances, the question arises, whether complainant is entitled to medical reimbursement of Rs.38,961/-. Annexure Nos.1 and 2 are the previous documents. Annexure-3 is the policy applicable to the present case which was in force from 11.04.2019 to 10.04.2020. The sum assured insured amount was Rs.6,25,000/-. Even though complainant is the insured but her son Nishanth.S and another son Akash Prasad.S. are the beneficiaries.
- The complainant got provided the treatment for her son Nishanth.S in Columbia Asia Referral Hospital, Yeshwanthpura, Bangalore City and she has spent Rs.32,861/- and Rs.6,100/-. It means, the complainant has incurred expenses of Rs.38,961/-. Even though, OPs have filed calculation sheet showing final admissible amount of Rs.22,254/-. Despite legal notice and request letter, the OPs failed to reimburse entire expenses of Rs.38,961/-. The OPs are not placed any material how the complainant is entitled only reimbursement of Rs.22,254/-. In the absence of any explanation on the part of OPs, the complainant is entitled to reimbursement of entire medical expenses of Rs.38,961/-.
- It is true that the cashless facility was repudiated. However, subsequently, the OPs have repudiated the claim. No explanation is placed by the OPs for repudiation of entire claim of Rs.38,961/-. In the absence of any valid reason for repudiation, the complainant is entitled to reimbursement of Rs.38,961/-. The non-reimbursement of this amount amounts to deficiency of service on the part of OPs.
- The complainant claims Rs.5,00,000/- as a compensation. But, this quantum neither pleaded nor proved and moreover there is no base to such a huge compensation. Even though, complainant contends that she got arranged Rs.38,961/-. But, it is not the case of the complainant that she was forced to pay the interest on Rs.38,961/-. Under such circumstances, it is proper to award compensation of Rs.15,000/- only. The complainant has availed service of advocate, cost of litigation is quantified at Rs.2,000/- as complainant has paid only Rs.230/- towards court fee and stamp duty on vakalath.
- Point No.3:- In view of the discussion referred above, complaint requires to be allowed in part. OPs are liable to reimburse Rs.38,961/- to the complainant with compensation of Rs.15,000/- and Rs.2,000/- towards cost of litigation. We proceed to pass the following
O R D E R - The complaint is allowed in part.
- Both OPs are directed to reimburse Rs.38,961/- with compensation of Rs.15,000/- and Rs.2,000/- towards cost of litigation.
- The OPs shall comply this order within 60 days from the date of receipt of order.
- Furnish the copy of this order and return the documents to the complainant with extra pleadings.
(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 24th day of February, 2022) (Renukadevi Deshpande) MEMBER | (K.S.BILAGI) PRESIDENT |
Documents produced by the Complainant which are as follows:- 1. | Ex.A.1 – Copy of policy bond | 2. | Ex.A.2 – Copy of common proposal form | 3. | Ex.A.3 – Copy of renewal endorsement | 4. | Ex.A.4 – Copy of tax invoice dated 09.04.2019 | 5. | Ex.A.5 – Copy of premium certificate | 6. | Ex.A.6 – Copy of acknowledgement for renewal of policy | 7. | Ex.A.7 – Copy of advance premium receipt | 8. | Ex.A.8 – Copy of Aadhar card of Nishanth.S. | 9. | Ex.A.9 – Copy of customer identity card issued to Nishanth.S | 10. | Ex.A.10 – Copy of medical bills | 11. | Ex.A.11 – Copy of discharge summary | 12. | Ex.A.12 – Copy of rejection letter issued by OPs | 13. | Ex.A.13 – Copy of letter issued by M/s Columbia Asia Hospital | 14. | Ex.A.14 – Copy of legal notice dated 15.05.2019. | 15. | Ex.A.15 – Copy of courier receipts | 16. | Ex.A.16 – Copy of acknowledgements |
(Renukadevi Deshpande) MEMBER | (K.S.BILAGI) PRESIDENT |
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