BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE

                                                                   Dated this the 21^st of January 2011

PRESENT

                                                  SMT. ASHA SHETTY           :   PRESIDENT

                                                                      SRI. ARUN KUMAR K.        :   MEMBER

COMPLAINT NO.114/2010

(Admitted on 27.03.2010)

Mrs. Vandana Baliga,

Wo. Surendra Baliga,

Aged about 57 years,

RA. F.No.8 40 2,

Vyas Nagar Housing Complex,

Behind K.P.T. Polytechnic,

Mangalore.                                       …….. COMPLAINANT

(Advocate for the Complainant: Sri.B.Guruprasad Shetty)

          VERSUS

National Insurance Company Limited,

Office Situated No.30,

Bharath Building,

P.M. Rao Road, Mangalore,

Rep. by its Divisional Manager.           ……. OPPOSITE PARTY

(Advocate for the Opposite Party: Mrs.Hemalatha Mallya).

                                      ***************

ORDER DELIVERED BY PRESIDENT SMT. ASHA SHETTY:

1.       This complaint is filed under Section 12 of the Consumer Protection Act alleging deficiency in service against the Opposite Party claiming certain reliefs. 

The brief facts of the case are as under:

The Complainant submits that, she had obtained Mediclaim Insurance Policy bearing policy No.602300/48/07/8500000753, valid from 14.12.2007 to 13.12.2008 and subsequently the said policy has been renewed with the policy No.602300/48/08/ 8500000689 valid from 14.12.2008 to 13.12.2009 for a sum of Rs.1,00,000/-. 

It is stated that, the Complainant had some health problem in connection with her spinal cord and admitted to K.M.C hospital on 17.04.2009, undergone nuero surgery and got discharged from the hospital on 16.05.2009 and spent Rs.1,23,370/-. Thereafter, the Complainant submitted the bill for medical reimbursement but the Opposite Party had settled the claim to the tune of Rs.89,174/- as against Rs.1,23,370/-.  It is stated that, the Complainant once again admitted to the aforesaid hospital on 05.06.2009 and taken treatment upto 11.06.2009 and incurred Rs.15,253.33 and Rs.2,482.83 for the pharmacy charges in respect of the 2^nd time treatment taken in the said hospital.  The medical treatment taken by the Complainant for the 2^nd time is also due for the same reason.  It is stated that, inspite of sending the registered notice to the Opposite Party by the Complainant, the Opposite Party has not complied and hence the above complaint filed under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Forum to the Opposite Party to pay a total sum of Rs.51,932.16 along with interest at 12% p.a. from the date of hospitalization and also claimed Rs.25,000/- as compensation and cost of the proceedings.

2.       Version notice served to the Opposite Party by RPAD. Opposite Party appeared through their counsel filed version, admitted the policy and stated that, the said policy is valid for the period from 14.12.2008 to 13.12.2009 and the sum insured was Rs.1,00,000/- only and Rs.50,000/- bonus, in total the liability comes to Rs.1,50,000/- only. 

The Complainant was admitted to the hospital for the 1^st time in the month of March i.e., on 12.03.2009 and was inpatient till 17.03.2009 and submitted the bill for Rs.11,156/- through KMC Mangalore.  The Opposite Party by considering the policy conditions and exclusions, paid Rs.10,826/- to the KMC. That the Complainant was re-admitted to the hospital for the 2^nd time on 17.04.2009 to 16.05.2009 and the same was considered and later bill for Rs.1,23,369/- has been forwarded to Third Party Administrator (herein after called ‘TPA’) and after considering the limit, paid Rs.89,174/- to the KMC.  The Complainant was admitted to the hospital for the 3^rd time on 05.06.2009 to 11.06.2009 and medical bills for Rs.17,736/- was submitted, the TPA was not aware of the fact of bonus has refused the claim made by the Complainant.  After receipt of the legal notice dated 03.11.2009 the Opposite Party has came to know about the illness and transaction and asked the TPA to re-consider the claim and sent the voucher for Rs.33,726/- for which the Complainant is entitled for.  Instead of discharging the voucher the Complainant has approached this Forum and it is stated that, there is no deficiency and prayed for dismissal of the complaint.

3.       In view of the above said facts, the points now that arise for our consideration in this case are as under:

1. Whether the Complainant proves that the Opposite Party has committed deficiency in service?

2. If so, whether the Complainant is entitled for the reliefs claimed?

3. What order?

4.         In support of the complaint, Mrs.Vandana Baliga (CW1) filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on her.   Ex C1 to C9 were marked for the Complainant as listed in the annexure.   One Sri.Manjunath Mysore (RW1), Divisional Manager of the Opposite Party filed counter affidavit and answered the interrogatories served on him.  Ex R1 to R6 were marked for the Opposite Party as listed in the annexure.   The Complainant produced notes of arguments.

          We have considered the notes/oral arguments submitted by the learned counsels and also considered the materials that was placed before this Forum and answer the points are as follows:

                       Point No.(i): Affirmative.

                       Point No.(ii) & (iii): As per the final order.   

Reasons

5.  Point No. (i) to (iii):

In the instant case, the facts which are not in dispute is that, the Complainant along with her husband one Mr.Surendra Baliga had jointly taken a Mediclaim Insurance Policy having the benefit of hospitalization from the Opposite Party.  The Complainant and her husband had issued with the policy No. No.602300/48/07/ 8500000753, the said policy was valid from 14.12.2007 to 13.12.2008 and subsequently the said policy has been renewed and the same was valid from 14.12.2008 to 13.12.2009.  It is also admitted that, the above said policy was insured for Rs.1,00,000/- and bonus of Rs.50,000/- in total Rs.1,50,000/-.  It is further admitted that, the Complainant was initially admitted to the hospital for the 1^st time in the month of 12^th March 2009 and was inpatient till 17.03.2009 and spent Rs.11,156/- for the hospitalization and thereafter for the 2^nd time, she had admitted on 17.04.2009 to 16.05.2009 to the KMC Hospital and spent Rs.1,23,369/- for the hospitalization and thereafter for the 3^rd time, she admitted to the hospital on 05.06.2009 to 11.06.2009 and spent Rs.17,736/-.  Further admitted that, Opposite Party paid Rs.10,826/- for the 1^st claim and for the 2^nd claim they have paid Rs.89,174/- and for the 3^rd claim they have issued a discharge voucher for Rs.33,726/-.

The grievances of the Complainant is that, she has spent Rs.1,49,000/- for the hospitalization on the three different occasions but the Opposite Party not reimbursed the claim as she entitled for a sum of Rs.1,50,000/-.

The Opposite Party on the other hand, though admitted the policy and the sum insured plus bonus for Rs.1,50,000/- but it is stated that, the claim was entrusted to the Third Party Administrator (herein after called ‘TPA’), as TPA was not aware of the fact that the bonus incurred by the Complainant, the TPA has refused the claim of the Complainant and after receipt of the legal notice dated 03.11.2009 issued by the counsel for the Complainant, the Opposite Party was aware of the fact of bonus incurred by the Complainant and re-considered the claim and sent a voucher for Rs.33,726/- but the same has been refused by the Complainant.  But on 09.11.2010 the Opposite Party filed a memo along with cheque for Rs.33,726/-, the same has been deposited before the D.F. Account. 

On perusal of the oral as well as documentary evidence placed on record, we find that, admittedly the Complainant entitled for Rs.1,50,000/- under the policy No.602300/48/08/8500000689 which includes the bonus of Rs.50,000/-.  There are three claims submitted to the Opposite Party on three different occasions by the Complainant.  The Opposite Party also filed memo of calculation before this FORA.

We have perused the policy conditions, wherein, the Company undertaken to pay the insured persons the amount of such expenses as would fall under different heads but not exceeding the sum insured in aggregate mentioned in the schedule hereto:-

1. Room, boarding, nursing expenses as provided by the hospital/nursing home which includes admission in IC Unit, over all limit under the policy is 25% of the sum insured per illness.
2. 25% of the sum insured for surgeon, anesthetist medical practitioner, consultants specials fees.
3. 50% of the sum insured for anesthesia, blood, oxygen, OT charges, surgical appliances, medicines, drugs, etc. etc but the above expenses was incurred for the same illness.

The memo of calculation filed by the Opposite Party appears to be correct and the Complainant is entitled only Rs.1,33,726/- as per the policy conditions.  However, the Opposite Party admitted their mistake in their version stating that, after receipt of the legal notice of the Complainant dated 03.11.2009 the Opposite Party was aware of the fact that the bonus was not considered.  The above acts of the Opposite Party amounts to deficiency in service.  However, because of their lapse, the Complainant was forced to file this complaint, in other words, the Complainant was forced to engage the service of the legal practitioner to get the claim and incurred unnecessary expenses.  Hence, the Complainant is entitled for the reasonable compensation in this case.  By considering the above, we direct the Opposite Party i.e., National Insurance Company Limited, represented by its Divisional Manager to pay Rs.3,000/- as compensation for the inconvenience and Rs.1,000/- as cost of the litigation expenses. Since the Opposite Party already deposited the difference amount of Rs.33,726/- before this FORA, the question of further direction does not arise.  

6.       In the result, we pass the following:                          

ORDER

            The complaint is allowed.  Opposite Party i.e., National Insurance Company Limited,           represented by its Divisional Manager is hereby directed to pay Rs.3,000/- (Rupees three thousand only) as compensation and Rs.1,000/- (Rupees one thousand only) as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.

  On failure to pay the compensation amount within the stipulated time as mentioned above the Opposite Party is hereby directed to pay interest at the rate of 10% p.a. from the date of failure till the date of payment.

The copy of this order as per the statutory requirements be forwarded to the parties free of charge and therefore the file be consigned to record.

(Page No.1 to 9 dictated to the Stenographer typed by her, revised and pronounced in the open court on this the 21^st day of January 2011.)

         PRESIDENT                                        MEMBER                                 

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1 – Mrs.Vandana Baliga – Complainant.

Documents produced on behalf of the Complainant:

Ex C1 – 29.05.2009: Fax copy of the letter issued by the Vipul MedCorp TPA Pvt. Ltd to the KMC Hospital, Mangalore.

Ex C2 – 17.04.2009: Copy of the bill for Rs.1,23,370/- for the treatment for the period from 17.04.2009 to 16.05.2009 issued by K.M.C. Hospital.

Ex C3 –                  : Original policy schedule issued to the Complainant for the period from 14.12.2008 to 13.12.2009.

Ex C4 – 03.11.2009: Lawyer’s notice issued to the Opposite Party.

Ex C5 -                 : Postal acknowledgement.

Ex C6 – 12.11.2009: Reply of the Opposite Party to the legal notice dated 03.11.2009 (Original).

Ex C7 – 10.12.2009: Endorsement issued by the Opposite Party for having received the original bills and report.

Ex C8 – 26.01.2010: Original discharge voucher issued by the Opposite Party for Rs.28,850/-.

Ex C9 – 26.01.2010: Copy of the discharge voucher issued by the Opposite Party for Rs.33,726/-.

Witnesses examined on behalf of the Opposite Party:

RW1 – Sri.Manjunath Mysore, Divisional Manager of the Opposite Party.

Documents produced on behalf of the Opposite Party:    

Ex R1 –                  : Hospitalization Benefit Policy bearing policy No.602300/48/08/8500000689 for the period from 14.12.2008 to 13.12.2009 along with terms and conditions.

Ex R2 – 26.01.2010: Discharge voucher for Rs.33,726/-.

Ex R3 -                 : Memo of calculation.

Ex R4 -                 : Inpatient file No.1 with all documents.

Ex R5 -                 : Inpatient file No.2 with all documents.

Ex R6 -                 : Inpatient file No.3 with all documents.

Dated:21.01.2011                                 PRESIDENT