COMPLAINT FILED: 30.10.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> 17th FEBRUARY 2009<br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT<br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI. A. MUNIYAPPA MEMBER <br /> <br /> COMPLAINT NO. 2325/2008<br /> <br /> <br /> COMPLAINANT Smt. Shakuntala Damodar,<br /> W/o. K. Damodar,<br /> Aged about 54 years,<br /> No. 89, Karishma Hills,<br /> Gubbalala Village,<br /> Bangalore – 560 061.<br /> <br /> Advocate (S.M. Ravindra Reddy)<br /> <br /> <br /> V/s.<br /> <br /> <br /> OPPOSITE PARTIES 1. National Insurance Company Limited,<br /> Division No. 14, <br /> Sterling Cinema Building,<br /> No. 65, II Floor, <br /> Murzaban street,<br /> Mumbai – 400 001.<br /> <br /> 2. Winner Insurance <br /> Benefits Limited,<br /> No. 27-A, Vatsa House, <br /> 4th Floor, Janmabhoomi Marg,<br /> Fort,<br /> Mumbai – 400 001.<br /> <br /> Advocate (Ravi. S. Samprathi)<br /> <br /> 3. E-Meditek Solutions Limited,<br /> #306, Konarkshram,<br /> No. 156, Tardeo Road,<br /> Mumbai – 34.<br /> <br /> 4. D.B.K.D.O., JAIN EKKAM,<br /> No. 44B, 1st Main Road,<br /> 3rd Phase, J.P. Nagar,<br /> Opp. Mini Forest,<br /> Bangalore – 560 078.<br /> <br /> <br /> O R D E R<br /> <br /> This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction to the Opposite Party (herein after called as O.P) to settle the insurance claim and reimburse the medical expenses of Rs.41,034/- and pay a compensation of Rs.50,000/- on an allegations of deficiency in service. <br /> <br /> The brief averments, as could be seen from the contents of the complaint, are as under:<br /> Complainant availed the group insurance family floater policy with medicare parivar issued by OP.1 under OP.2 which was valid from 01.05.2005 to 30.04.2006. During the month of September she felt some abdominal pain, hence approached Dr. Malathi Memorial Hospital, Bangalore. She was hospitalized from 22.09.2005 to 24.09.2005 and underwent Hysterectomy. Thereby incurred hospital expenses of Rs.41,034/-. After the discharge she sent the entire bills and other records to OP for processing her medical expenses and to reimburse the same. She addressed a letter to OP.2 on 23.09.2005 itself. Though OP received the said claim, kept it pending without any sufficient reason or cause, inspite of the repeated requests and demands made by the complainant. Being fed up with the hostile attitude of the OP complainant got issued the legal notice on 16.05.2008. Again there was no response. Under such circumstances complainant felt the deficiency in service on the part of the OP’s. Hence she is advised to file this complaint and sought for the relief accordingly.<br /> <br /> 2. On admission and registration of the complaint, notices were sent to the OP’s. OP.4 served with a notice remained absent, hence placed ex-parte. Complainant failed to take proper steps against OP.3, hence complaint came to be dismissed against OP.3. It is only OP.1 and OP.2 who contested the matter and filed their version. The defence set out by OP.1 and 2 in the nutshell is the complaint is barred by time. Complainant has violated the terms and conditions of the policy. OP.3 is a 3rd party administrator. When OP.1 and 2 received the said claim they immediately forwarded it to OP.3 for processing. No negligence or carelessness muchless deficiency in service lies with OP.1 and 2. After thorough investigation and on going through the records OP.1 rejected the said claim. OP.2 contended that when OP.1 rejected the said claim, it has nothing to do because it only acts as an Agent of OP.1. Complainant is expected to produce all the records and documents within 7 days from the date of discharge from the hospital. She has not kept up that condition. Hence it is treated as no claim. The other allegations made by the complainant are baseless. The complaint is devoid of merits. Among these grounds, OP prayed for the dismissal of the complaint.<br /> <br /> 3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced some documents. OP.1 and 2 has also filed the affidavit evidence. Then the arguments were heard.<br /> <br /> 4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under:<br /> <br /> Point No. 1 :- Whether the complainant has proved <br /> the deficiency in service on the part of the OP?<br /> <br /> Point No. 2 :- If so, whether the complainant is <br /> entitled for the reliefs now claimed?<br /> <br /> Point No. 3 :- To what Order?<br /> <br /> <br /> 5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on:<br /> <br /> Point No.1:- In Affirmative<br /> Point No.2:- Affirmative in part<br /> Point No.3:- As per final Order.<br /> <br /> <br /> R E A S O N S<br /> <br /> 6. The fact that the complainant became the member of group insurance family floater scheme with Medicare Parivar issued by OP.1 under OP.2 which was valid from 01.05.2005 to 30.04.2006 is not at dispute. The sum assured/indemnified is Rs.1,00,000/-. According to the complainant she suffered pain in abdominal in the month of September 2005, hence approached Dr. Malathi Memorial Hospital, Bangalore. On examination it was diagnosed that she is suffering from hysterectomy. She was hospitalized between 22.09.2005 to 24.09.2005, ultimately she underwent the operation. On 23.09.2005 complainant sent a letter to the OP.2 about her hospitalization. Complainant incurred hospital expenses of Rs.41,034/-. The connected hospital records, discharge summary and bills, etc., are produced.<br /> <br /> 7. On going through the defence of OP.1 and 2 nowhere they have disputed the fact of complainant having spent Rs.41,034/- towards her treatment. After the discharge complainant made claim to OP by addressing a letter in the month of October 2005, it appears OP’s started throwing the burden against each other and shifted the headache. Though she patiently waited for months together OP did not settle her claim, ultimately she got issued the legal notice on 16.05.2008. The copy of the legal notice is produced. The evidence of the complainant finds full corroboration with the contents of the hospital records, letters, discharge summary, reports, hospital bills as well as the correspondence and legal notice caused to the OP. There is nothing to discard her sworn testimony. It is a quality of evidence that is more important than that of the quantity.<br /> <br /> 8. As against this unimpeachable evidence of the complainant, the defence set out by the OP appears to be defence for defence sake, just to avoid their responsibility and obligation. OP.1 and 2 have contended that the complaint is barred by time. We do not find force in the said defence because as long as the claim of the complainant is not repudiated after due application of mind, she has got a right to redress her grievance. The very defence goes to show that each one of these OP’s want to shift the burden and responsibility against another. This kind of treatment to the consumer like complainant, who took the medi claim family floater policy with a good belief and faith rather scattered their confidence. It is unfortunate. They have kept the said claim pending without due consideration, speaks loudly about their carelessness and negligence. OP.2 says that claim ought to have been made within 7 days from the date of discharge. Why such kind of technical defence is raised when the genuine claim is made is not known. <br /> <br /> 9. We have closely scrutinized both oral and documentary evidence, we are satisfied that the complainant is able to prove the deficiency in service on the part of OP.1 and 2. For no fault of her, she is made to suffer both mental agony and financial loss. Under such circumstances she is entitled for certain relief. Accordingly we answer point nos.1 and 2 and proceed to pass the following: <br /> O R D E R<br /> <br /> The complaint is allowed in part. OP.1 and 2 are directed to reimburse the medial expenses of Rs.41,034/- within 4 weeks from the date of communication of this order and also pay a litigation cost of Rs.1,000/-. Failing in which the complainant is entitled to claim interest at the rate of 9% p.a. on the said amount from November 2005 till realization along with a litigation cost.<br /> <br /> (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 17th day of February 2009.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> p.n.g. <br />