Date of Filing:16.09.2008<br /> Date of Order:09.02.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> <br /> Dated: 9TH DAY OF FEBRUARY 2009<br /> PRESENT<br /> <br /> <br /> <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 /> COMPLAINT NO: 2028 OF 2008<br /> <br /> Zacharia Xavier<br /> No. 158, Athikalam<br /> Gandhi Road, Kamanahalli<br /> St. Thomas Town P.O.<br /> Bangalore 560 084 Complainant<br /> V/S<br /> National Insurance Company Ltd.<br /> Bangalore Divisional Office – 7<br /> 982, 2nd Floor, 80 feet Peripheral Road<br /> Koramangala, Bangalore 560 034 Opposite Party<br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a mediclaim claimed by the complainant. <br /> The facts of the case are that the complainant has taken mediclaim policy and paid premium of Rs. 14,697/- on 14.06.2007. The policy is supposed to be cashless hospitalisation i.e. the bill will go directly from the hospital to the insurance company and they will settle the payment directly. The mother of the complainant 73 years old fell down in the bathroom on 17.09.2007 and she was admitted to hospital in Bangalore on the same day and she was discharged on 19.09.2007. The hospital authorities told him to pay the bill. He was shocked and did not know what to do. He called his friends and relatives and with heavy interest he managed to raise the money and paid the same to hospital and got discharged his mother. He kept asking insurance company for the reason why his claim was rejected. On 25.01.2008 opposite party replied that his mother has undergone treatment for some existing sickness and that does not cover insurance. He went to the doctor who had treated his mother and got the certificate from him on 15.02.2008 saying that treatment was given because she fell down and not for any existing sickness. Inspite of the letter which was given to the insurance company the complainant states that nothing happened. Ever since he is running from pillar to post for getting claim but to no use. Because of this he is unable to do business and to work. Therefore, he approached the Consumer Forum to get the claim. Complainant has claimed Rs. 52,736/- towards mediclaim amount and Rs. 10,000/- towards interest for borrowing amount and Rs. 50,000/- towards loss of business and Rs. 25,000/- for mental torture. In this way the complainant has claimed Rs. 1,37,736/- from the opposite party.<br /> 2. Notice issued to opposite party. The opposite party put in appearance through advocate and defence version submitted. It is admitted by the opposite party that complainant has taken mediclaim health policy. It is also admitted the policy is called hospitalisation benefit policy. The opposite party also admitted that the claim has been received and claim falls under exclusion of clause 4.1 and 4.10 of mediclaim policy which states that all diseases / injuries which are pre-existing when the cover incepts for the first time was not payable. Hence, the claim was not admissible. Same was informed to the complainant. The opposite party submitted that there is no deficiency of service on their part. Therefore, requested to dismiss the complaint.<br /> 3. Affidavit evidences are filed. Documents are also filed.<br /> 4. Arguments are heard.<br /> 5. The points for consideration are:<br /> 1. Whether the opposite party is justified in repudiating the claim?<br /> 2. Whether the complainant is entitled for the claim?<br /> REASONS<br /> 6. It is admitted case of the parties that the complainant had taken hospitalisation benefit policy for his mother and his family members. The sum assured for his mother is Rs. 1,00,000/-. The policy covered period from 17.07.2007 to 16.07.2008. The complainant has produced policy. The admitted case of the parties is that the mother of the complainant Smt. Annamma Xavier fell down in the bathroom on 17.09.2007 and the complainant took her mother to Manipal Hospital on the same day. He has admitted her to hospital and treatment was given there and discharged from hospital on 19.07.2007. The complainant has produced a certificate from Manipal Hospital dated 15.02.2008 given by Dr. Hemant K. Kalyan, Consultant Orthopaedician, Manipal Hospital. Doctor has stated in the certificate as under:<br /> “This is to certify that Mrs. Annamma Xavier was admitted under my care on 17.09.2007 and was discharged on 19.09.2007. Details of diagnosis can be found in the discharge summary which is enclosed.<br /> <br /> Please note that the primary reason for the admission was slip and fall in the bathroom which was of 5 days duration. The investigations confirmed that she had sustained a compression fracture L1 Vertebra as a result of the injury and not as a complication of Carcinoma Cervix. There was no evidence of metastasis seen on the bone scan and MRI Scan. MRI Scan confirmed hemorrhage along the psoas muscles bilaterally suggestive of a post traumatic etiology.<br /> <br /> This is for your kind information.<br /> <br /> Sd/-<br /> Dr. Hemant K. Kalyan<br /> Consultant Orthopaedician<br /> Manipal Hospital”<br /> 7. The complainant has also produced discharge summary. In the discharge summary also it is clearly stated that patient presented with slip and fall in the bathroom on Wednesday and complained of pain in low back after the fall. In the past history it is stated Ca cervix since 7 years, taken radiotherapy in BIO. Hypertensive for last 10 years on medication. DM since one year on treatment. The Doctor who has treated the patient Dr. Hemant Kalyan has given certificate that the patient sustained L1 vertebra as a result of the injury and not as a complication of Carcinoma Cervix. Therefore, as per the Doctor’s certificate it is very clear that the treatment given to the mother of the complainant is not for preexisting disease or injury. The exclusion of clause of 4.1 and 4.10 is relied on by the opposite party is not at all applicable to the facts of the present case. There is no question of taking treatment to the pre-existing disease. This is simple case of fall / slip in the bathroom and the mother of the complainant sustained fracture and she was treated for injury. It is very unfortunate on the part of the opposite party company to deny the claim of the complainant for very whimsical and untenable reasons. The opposite party company should have accepted the claim and paid the claim amount to the complainant immediately. The insurance company after taking premium amount had issued hospitalisation benefit policy. When the genuine claim is put up by the complainant for acceptance and bill amount paid towards treatment of his mother the company has not taken any interest to pay the claim immediately. On the other hand the company had taken very untenable and un-reasonable defence. The complainant being a man of financial difficulty he was shocked by the attitude of the company. The hospital authorities refused to discharge his mother without paying the bill amount and he has to raise the amount by paying interest and thereby he suffered mental shock and agony and also financial loss. This trend of insurance company is not proper. The insurance company should help the policy holder immediately after getting the claim instead of taking untenable defence. Consumer Protection Act is a social and benevolent legislation intended to protect the better interests of the consumer. The Consumer Protection Act is a mile stone in the history of the socio economic legislation and is directed towards achieving the public benefit. The Act attempts to remove the helplessness of Consumer which he faces against the powerful business house or Company. The complainant has claimed Rs. 52,736/- towards mediclaim which he has paid to Manipal Hospital. He has produced bill of Manipal Hospital. The opposite party is bound to pay this amount. Sum assured is Rs. 1,00,000/-. The opposite party is also liable to pay interest on that amount from the date of payment made to the hospital. The complainant has prayed compensation for mental torture, agony etc. Since the interest is awarded that will take care of the delay in making payment. Therefore, we are not inclined to grant any compensation to the complainant for mental agony etc. In the result I proceed to pass the following:<br /> <br /> ORDER<br /> 8. The Complaint is allowed. The opposite party is directed to pay Rs. 52,736/- (claim amount) to the complainant within 30 days from the date of the order. The opposite party is also directed to pay 12% interest on the above amount from 19.09.2007 till payment / realisation.<br /> 9. The complainant is entitled for Rs. 2,000/- towards costs of the present proceedings.<br /> 10. Send the copy of this Order to both the parties free of costs immediately. <br /> 11. Pronounced in the Open Forum on this 9TH DAY OF FEBRUARY 2009. <br /> Order accordingly,<br /> <br /> <br /> PRESIDENT<br /> We concur the above findings.<br /> <br /> <br /> MEMBER MEMBER<br />