COMPLAINTS FILED ON: 29.06.2009<br /> DISPOSED ON: 24.07.2010 <br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> 24TH JULY 2010<br /> <br /> PRESENT:- SRI. B.S. REDDY PRESIDENT<br /> SMT. M. YASHODHAMMA MEMBER<br /> SRI. A. MUNIYAPPA MEMBER <br /> <br /> <br /> COMPLAINT Nos.1529, 1531 & 1532/2009<br /> <br /> <br /> COMPLAINT NO.1529/09<br /> COMPLAINANT<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Smt. Pushparani S.,<br /> D/o Somashekar,<br /> Aged about 22 years,<br /> 1/22, Byrappa Compound,<br /> Lingarajapuram,<br /> Bangalore – 560 084.<br /> <br /> M/s Swastik General & Health Care Services (P) Ltd.,<br /> Kamadhenu Corner, No.399, <br /> II Floor, 1st Main, 1st Stage, <br /> 3rd Phase Manjunatha Nagar,<br /> WOC Main Raod,<br /> Bangalore – 560 010.<br /> <br /> Rep: by its Authorized signatory<br /> Sri Jayaram K.B. <br /> <br /> <br /> COMPLAINT NO.1531/09<br /> COMPLAINANT<br /> Sriram T.R.,<br /> S/o Ramappa,<br /> Aged about 25 years,<br /> 75, 1st Cross, Haralur Village,<br /> Bellandur Gate, Sarjapura Road.<br /> <br /> Rep: by his Power Attorney Holder.<br /> <br /> <br /> <br /> M/s Swastik General & Health Care Services (P) Ltd.,<br /> Kamadhenu Corner, No.399, <br /> II Floor, 1st Main, 1st Stage, <br /> 3rd Phase Manjunatha Nagar,<br /> WOC Main Raod,<br /> Bangalore – 560 010.<br /> <br /> Rep: by its Authorized signatory<br /> Sri Jayaram K.B. <br /> <br /> <br /> COMPLAINT NO.1532/09<br /> COMPLAINANT<br /> Mohammed Sab,<br /> S/o Raja Sab,<br /> Aged about 46 years,<br /> Sulekal Oni, Kanakagiri Post,<br /> Koppal, <br /> Gangavathi Taluk – 584 119. <br /> <br /> Rep: by his Power Attorney Holder.<br /> <br /> M/s Swastik General & Health Care Services (P) Ltd.,<br /> Kamadhenu Corner, No.399, <br /> II Floor, 1st Main, 1st Stage, <br /> 3rd Phase Manjunatha Nagar,<br /> WOC Main Raod,<br /> Bangalore – 560 010.<br /> <br /> <br /> Advocate: Sri K. Surendra Babu<br /> <br /> <br /> V/s.<br /> <br /> <br /> OPPOSITE PARTY M/s New India Assurance Co. Ltd.,<br /> D.O.-7, 5th Floor, D.J.C. Buildings,<br /> (Vokkaligara Bhavana),<br /> Hudson Circle,<br /> Bangalore – 560 027.<br /> <br /> Advocate: Sri. C.R. Ravishankar<br /> <br /> <br /> O R D E R S<br /> <br /> SRI. B.S. REDDY, PRESIDENT<br /> <br /> These are the complaints filed U/s. 12 of the Consumer Protection Act of 1986, by the respective complainants seeking direction against Opposite Party (herein after called as O.P) to reimburse the medical expenses with interest at 18% p.a. and for compensation of Rs.10,000/- each on an allegations of deficiency in service on the part of the OP. <br /> <br /> The OP in all these complaints are common, the questions involved are similar, in order to avoid the repetition of facts and reasonings all these complaints are disposed of by this common order. <br /> <br /> 2. The claim of the complainants in each complaint is furnished in the following chart:<br /> <br /> Sl. No. Complaint No. Amount Claimed<br /> 1 1529/09 Rs.12,477/-<br /> 2 1531/09 Rs.14,563/-<br /> 3 1532/09 Rs.33,500/-<br /> <br /> The complainants in all these complaints had taken Personal Accident Group Insurance with OP against the accidental injury through M/s Swastik General and Health Care Services Pvt. Ltd., The upper limit of the policies is Rs.1,00,000/- the policies were valid on the date of accident. <br /> <br /> 3. The case of the complainant in complaint No.1529/09 is that the complainant met with an accident on 15.01.2009, she underwent medical treatment and incurred expenses to the tune of Rs.29,290/-, OP settled the said claim. Subsequently the complainant under went another surgery for removal of pin and incurred medical expenses of Rs.12,477/- and submitted the bills for settlement. OP repudiated the claim on the ground that as per the terms and conditions of the group insurance policy the reimbursement is to be made is one time settlement and there is no provision for reimbursement of medical expenses time and again in respect of the same accident. Further it is stated that OP has no intimation regarding insertion of pin and its subsequent removal by surgery. The subsequent surgery after settlement of claim falls beyond the scope of insurance policy and OP is not liable to reimburse medical expenses claimed for the second time. <br /> <br /> 4. The case of the complainant in complaint No.1531/2009 is that he has met with an accident on 19.08.2008, as his vehicle hit by car and he sustained injuries and he took treatment in St. John’s Medical College Hospital and incurred medical expenses of Rs.14,563/-. He submitted claim for reimbursement of medical expenses OP repudiated the claim on the ground that the name of the injured is Ramu, but the complainant is Sriram T.R. and also called by another name as Ramu. The name of the patient in the hospital records corrected from Ramu to Sriram T.R. on the request of the patient and the same cannot be taken into consideration for the purpose of processing the claim. <br /> <br /> 5. The case of the complainant in complaint No.1532/2009 is that on 01.05.2008 he was a pillion rider on two wheeler vehicle, the vehicle skidded and he fell down and sustained injuries, took medical treatment incurred medical expenses of Rs.33,500/- and submitted the medical bills for reimbursement, but the claim was repudiated on the ground that accident is not reported to the police and no FIR is lodged. The claim cannot be treated as accident case. <br /> <br /> 6. The authorized signatory of power of attorney holder of the complainants in all these complaints filed affidavit evidence to substantiate the complaint averments and produced documents. The Manager of OP filed the affidavit evidence in support of the defence version. <br /> <br /> 7. Written arguments filed all these complaints for complainants and OP. Arguments of the complainants side heard, arguments of OP side taken as heard. Points for consideration are: <br /> <br /> Point No.1:- Whether the complainants have proved <br /> the deficiency in service on the part of<br /> the OP in all these complaints? <br /> <br /> Point No.2:- If so, whether the complainants are <br /> entitled for the reliefs now claimed?<br /> <br /> Point No.3:- To what Order?<br /> <br /> 8. We record out findings on the above points are:<br /> <br /> Point No.1:- In Affirmative. <br /> Point No.2:- Affirmative in part. <br /> Point No.3:- As per final Order.<br /> <br /> R E A S O N S<br /> <br /> 9. In complaint No.1529/09 the complainant had taken medical treatment for the injury sustained in an accident on 15.01.2009, OP settled the medical expenses claimed to the tune of Rs.29,290/-. While the complainant was under going medical treatment another surgery for removal of pin was conducted and incurred medical expenses to the extent of Rs.12,477/-. OP has repudiated the claim on the ground that the group insurance policy reimbursement is confined to only one time settlement and there is no provision for reimbursement of medical expenses time and again in respect of the same accident. In our view OP was not justified in repudiating the claim on that ground. The removal of the pin by conducting the surgery is the direct consequence of the injury sustained in the accident. For the purpose of medical treatment of the injury, the pin was inserted and the same was removed subsequently by conducting surgery. Therefore it cannot be said that conducting surgery for removal of the pin is a injury subsequent not relating to injury on account of the accident which has taken place on 15.01.2009. Under these circumstances the complainant is entitled for the reimbursement of the said medical expenses of Rs.12,477/- and OP is liable to pay the said amount. <br /> <br /> 10. In complaint No.1531/09 the claim to reimburse the medical expenses to the tune of Rs.14,573/- was repudiated on the ground that the name of the injured is Ramu, but the complainant is Sriram T.R. The name of the patient in the hospital records is corrected from Ramu to Sriram T.R., the same cannot be taken into consideration for processing the claim. In our view by bonafide mistake while admitting the complainant his name has been shown as Ramu in the Hospital records, but later his name has been corrected in the records from Ramu to Sriram T.R. The fact that the complainant has sustained injury in the accident and took treatment at St. John’s Medical College Hospital is clear from the records available and produced before the OP. In view of the same OP was not justified in repudiating the claim. Under these circumstances the complainant is entitled for an amount of Rs.14,573/- and OP is liable to pay the same. <br /> <br /> 11. In complaint No.1532/09 on 01.05.2008 while complainant was pillion rider of two wheeler, on account of vehicle being skidded he fell down and sustained injury. He has incurred total medical expenses of Rs.33,500/- and submitted the medical bills for reimbursement. OP repudiated the claim on the ground that accident is not reported to the police and no FIR is lodged. In our view as per the principles laid down in II (2009) CPJ 216 (NC) Oriental Insurance Company Ltd., V/s Suresh Singh and another, the Hon’ble National Consumer Disputes Redressal Commission held that filing of FIR not compulsory to claim compensation under policy. In II (2009) CPJ 149 (NC) Gangothri Devi and others V/s National Insurance Co. Ltd., and another it was held that inability of family of deceased assured, to report the assured’s death to local police, not such serious lapse on their part to disentitle them altogether to insurance claim. Therefore merely because police complaint was not lodged and no FIR was registered in respect of the accident, is not a valid ground to repudiate the claim. The medical certificate issued by the hospital clearly states the cause of injury as fall from bike. The president of Gangavathi Taluk Decoraters and Suppliers Kshemabiruddi Sangha has issued the certificate stating that the complainant met an accident as pillion rider. From these materials; it is crystal clear that the complainant sustained injuries due to skid of two wheeler on which he was a pillion rider. OP was not justified in repudiating the claim. The complainant is entitled for the medical expenses incurred to an accident of Rs.33,500/- and is liable to pay the same. <br /> 12. There is no merit in the contention of OP in all these complaints that M/s Swastik General & Health Care Services (P) Ltd., allegedly settled the claim of these complainants and there is no insurable interest of the OP to settle the claim. Merely because the medical expenses incurred was paid by M/s Swastik General & Health Care Services (P) Ltd., It cannot be said that the insurance claim has been settled. OP cannot avoid it liability to settle the claim on the ground that the complainants have already taken medical expenses from M/s Swastik General & Health Care Services (P) Ltd., There is also no merit in the contention that the only allegations is regarding violation of solemn agreement which is civil in nature and this Forum has no jurisdiction. OP having collected the premium as service charges cannot contend that this Forum has no jurisdiction to entertain the claim. Under these circumstances we are of the view that the claimants proved deficiency in service on the part of the OP in not settling the claims. The claimants are entitled for the amounts claimed. Accordingly we proceed to pass the following: <br /> <br /> O R D E R<br /> <br /> The complaints are allowed in part.<br /> <br /> 1. In complaint No.1529/2009 OP is directed to settle the claim of the complainant at Rs.12,477/- and pay litigation cost of Rs.500/- to the complainant.<br /> <br /> 2. In complaint No.1531/2009 OP is directed to settle the claim of the complaint at Rs.14,563/- and pay litigation cost of Rs.500/- to the complainant.<br /> <br /> 3. In complaint No.1532/2009 OP is directed to settle the claim of the complainant at Rs.33,500/- and pay litigation cost of Rs.500/- to the complainant.<br /> <br /> This order is to be complied within four weeks from the date of this order. <br /> <br /> Send the copy of this order to both the parties free of cost.<br /> <br /> This original order shall be kept in the file of the complaint No.1529/2009 and a copy of it shall be placed in other respective files.<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 24th day of July 2010.) <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> Snm: <br />