Date of Filing: 17.06.2008<br /> Date of Order:14.08.2008<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> Dated: 14TH DAY OF AUGUST 2008<br /> PRESENT<br /> Sri. S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri. BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> <br /> <br /> <br /> <br /> COMPLAINT NO: 1338 OF 2008<br /> P. Kiran Sharma<br /> W/o. D. Pawan Kumar Sharma<br /> No. 65, Kali Temple Road<br /> T. Dasarahalli, 4th Cross<br /> Bangalore 560 057 Complainant<br /> <br /> V/S<br /> 1. National Insurance Co. Ltd.<br /> D.O. 14, Sterling Cinema Building<br /> No. 65, Marzaban Road, Fort<br /> Mumbai 400 001<br /> <br /> 2. Winner Insurance Benefit Ltd.<br /> Winner Beneficiary Trust<br /> No. 27A, Vatsa House<br /> 4th Floor, Janmahoomi Marg<br /> Fort, Mumbai 400 001<br /> <br /> 3. E-Mediteck Solutions Ltd.<br /> No. 45, DLF Phase 3<br /> Natapur Road<br /> Gurgaon 122 002<br /> <br /> 4. DBKDO Jain Ekkam<br /> Deluxe House<br /> No. 16, 1st Floor, 1st Cross<br /> Kalasipalyam New Extension<br /> Near SJ Park Police Station<br /> Bangalore 560 002 Opposite Parties<br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a complaint filed under section 12 of the Consumer Protection Act.<br /> The complainant has taken insurance coverage towards mediclaim from the opposite parties. The policy was renewed from 01.05.2005 to 30.04.2006. In the month of august 2005 complainant was suffering from severe headache and when she was admitted to hospital she was diagnosed for DNS with Pansinusitis / DM and was advised for septoplaisty with B/L spendoidctomy/B/L Maxillary clearance with B/L ethmoidectomy under GA. She was admitted to Bhagwan Mahaveer Hospital on 11.08.2005 for operation. Operation was conducted on 12.08.2005 and she was discharged from the hospital on 18.08.2005. Complainant was admitted to hospital as inpatient for 8 days. She incurred Rs. 20,650/- expenses. After discharge complainant submitted claim form along with discharge summary, bills etc. Opposite party No. 4 forwarded the claim to opposite party No. 3. In spite of receipt of the claim form along with all the annexure the opposite parties jointly failed and neglected to honour the legitimate claim. Opposite parties made the complainant to visit their office time and again. Opposite parties have not rejected the claim till date. Complainant has suffered physically and mentally at the hands of opposite parties. Therefore, complainant is entitled for damages of Rs. 1,00,000/- for pain and suffering. Complainant is entitled for mediclaim of Rs. 20,650/- alongwith interest. Complainant got issued legal notice on 21.04.2008 to the opposite parties. Inspite of service of notice opposite parties have neglected to reply or to settle the claim of the complainant. Hence, the complaint. <br /> 2. Notice was issued to opposite parties. Notice was sent to opposite parties No. 1 & 2 by RPAD. Inspite of service of notice they have not appeared before this forum. Therefore, they are placed as exparte. Opposite party No. 4 has sent reply through post stating that it had submitted claim to Winner Insurance Benefit Ltd. and National Insurance Co. Ltd. to settle the claim. Opposite party No. 3 not appeared and no version has been filed. <br /> 3. Arguments of learned advocate of the complainant heard. Perused the documents and the mediclaim policy taken by the complainant.<br /> 4. Opposite party No. 1 & 2 have issued mediclaim policy. Period of insurance was from 01.05.2005 to 30.04.2006. Amount of indemnity is Rs. 50,000/- to each member of the family. The complainant was suffering from illness and therefore, she was admitted to hospital. She was admitted to Bhagwan Mahaveer Jain Hospital on 11.08.2005 and discharged from hospital on 18.08.2005. The complainant has produced the bills of Bhagwan Mahaveer Jain Hospital, Bangalore. As per this bill and the discharge summary report it is clear that the complainant has paid Rs. 20,545/- to Bhagwan Mahaveer Jain Hospital. The amount was received by the hospital against receipt No. 5997 dated 18.08.2005. The complainant has produced another bill for Rs. 105/- of Ravi Kirloskar Memorial Hospital & Research Centre. This bill is dated 03.08.2005. The complainant has submitted cash less request form. Her request was not considered stating that the liability of the insurer is not determinable at this juncture. Hence, Cashless facility cannot be extended. Hospital is requested to collect the expenses from patient. However, the insurer can submit the papers after discharge for reimbursement as per the policy terms and conditions. After rejecting the cash less request form the complainant paid the hospital bill on her own and thereafter, submitted claim form along with annexures. The Medicare India submitted mediclaim form alongwith all the required documents including discharge summary, mediclaim bills etc. of the complainant to Winner Insurance Benefits Ltd. opposite party no. 2 for acceptance. The complainant has produced letter of Medicare India Ltd. dated 27.08.2005. In spite of submission of mediclaim form with necessary documents the opposite parties No. 1 & 2 have not paid the amount claimed by the complainant. The complainant was made to approach and visit the office of opposite parties time and again. She had moved pillar to post to get amount of Rs. 20,000/- and odd towards the amount spent for her treatment. It is unfortunate that the opposite party No. 1 & 2 though had received mediclaim policy for issuing premium amount have not taken care to allow the claim even after submission of all the documents and mediclaim form. This inordinate delay in allowing the claim is definitely deficiency in service on the part of the opposite parties. The opposite parties No. 1 & 2 though served with notice have not chosen to appear and contest the matter. It appears that they have no defence to make. That is why they remained absent. The case made out by the complainant deserves to be accepted as true and correct. There is nothing to disbelieve the facts stated by the complainant in her complaint. Therefore, the complaint deserves to be allowed. The complainant has claimed compensation of Rs. 1.00 lakh towards mental agony and hardship. From the facts and circumstances of the case it is not the case to grant compensation for mental agony and hardship. The grant of interest will meet the ends of justice. In the result I proceed to pass the following:<br /> ORDER<br /> <br /> 5. The complaint is allowed. The opposite parties No. 1 & 2 are directed to pay Rs. 20,650/- to the complainant towards her mediclaim. Opposite parties No. 1 & 2 are directed to pay interest at 18% p.a. on the above amount from the month of September 2005 till payment / realization.<br /> 6. Complainant is also entitled for Rs. 4,000/- towards costs of the present proceedings from opposite parties No. 1 & 2.<br /> 7. Send the copy of this Order to both the parties free of costs immediately. <br /> 8. Pronounced in the Open Forum on this 14TH DAY OF AUGUST 2008. <br /> Order accordingly,<br /> <br /> <br /> PRESIDENT<br /> We concur the above findings. <br /> <br /> MEMBER MEMBER <br /> <br /> <br /> <br /> CV<br /> <br />