COMPLAINTS FILED ON: 29.06.2009<br /> DISPOSED ON: 11.11.2010 <br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> DATED THIS THE 11TH NOVEMBER 2010<br /> <br /> PRESENT:- SRI. B.S. REDDY PRESIDENT<br /> SMT. M. YASHODHAMMA MEMBER<br /> <br /> COMPLAINT Nos.1530 & 1533/2009<br /> <br /> <br /> COMPLAINT NO.1530/09<br /> COMPLAINANT<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> COMPLAINT NO.1533/09<br /> COMPLAINANT<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> OPPOSITE PARTY<br /> Suresha,<br /> S/o Puttaiah,<br /> Aged about 32 years,<br /> Raghavendranagara,<br /> 1st Ward, Nelamangala Town,<br /> Bangalore Rural District,<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 /> Rep: by its Authorized signatory<br /> Sri Jayaram K.B. <br /> <br /> <br /> Shivalingaiah. B.D.,<br /> S/o Devaiah,<br /> Aged about 30 years,<br /> Booragana Doddi,<br /> Harisandra Post,<br /> Ramanagara Taluk and Post,<br /> <br /> Rep: by his Power Attorney Holder.<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 /> Advocate: Sri. K.Surendra Babu<br /> <br /> <br /> V/s.<br /> <br /> <br /> 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 /> O R D E R<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) for reimbursement of 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 both these complaints is common, the questions involved are similar, in order to avoid the repetition of facts and reasonings both 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 1530/09 Rs.37,033/-<br /> 2 1533/09 Rs.37,817/-<br /> <br /> The complainants in both 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.1530/09 is that he met an accident on 30.11.2008 while traveling in a car within Hassan Traffic Police Station Jurisdiction and sustained injuries, took first aid treatment at Hassan and later he was shifted Pristine Hospital, Rajajinagar, Bangalore for better treatment and incurred medical expenses of Rs.37,033/- submitted the bills. OP repudiated the claim on account various discrepancies like accident took place on 30.11.2008, but the same was reported to police on 03.03.2009 i.e., after lapse of 3 months 3 days, there is no proper reason for such inordinate delay, the complainant has not furnished the original FIR. The accident allegedly took place in Hassan, but there is no document regarding any treatment at least first aid treatment in Hasan and any reference for better treatment in hospital at Bangalore. <br /> <br /> 4. The case of the complainant in complaint No.1533/09 is that he met with industrial accident on 24.04.2008 and suffered fracture of right leg, he took first aid treatment in Bidadi and further treatment in Bangalore and submitted the medical bills with claim for medical reimbursement to an extent of Rs.37,817/-. OP repudiated the claim on the ground that the date of accident is left blank in the intimation letter. The complainant has not furnished documentary proof regarding medical treatment taken at Bidadi and there is no proper description of how the alleged accident took place. <br /> <br /> It is stated that in the beginning particular column accident date might have been left blank. After that several documents have been submitted by the claimant to substantiate his claim. In the said documents, date of accident can be ascertained clearly. After the accident claimant has taken preliminary treatment at Prashanthi Hospital at Bidadi as an out patient. The certificate issued by Dr. G.N. Chandrashekar clearly stated that the complainant has sustained injury to right knee joint and has treated as an out patient and referred to Bangalore for further treatment on 24.04.2008. In the discharge summary the doctor has clearly mentioned that the complainant has sustained right knee injury at working place at Crystal Granite 1 week back. OP is not disputed the surgery. The complainant is entitled for full reimbursement of Rs.37,817/-.<br /> <br /> 5. In the version filed the main defence of the OP in both the complaints are alleged violation of solemn agreement, which is civil in nature and beyond the scope and jurisdiction of the Forum. The complainants are not entitled to seek any relief for the simple reason that M/s Swastik General and Healthcare Services Pvt. Ltd., allegedly settled the claim of the complainants, there is no insurable interest of the OP to settle the claim. Hence there is nothing surviving for adjudication of the complaints. The complaints are liable to be dismissed. <br /> <br /> Further the defence in complaint No.1530/2009 is that OP rightly repudiated the claim as there are various discrepancies of the claim form and documents produced by the complainant. The alleged accident took place on 30.11.2008, but the accident reported to the police only on 03.03.2009 i.e., after lapse of 3 months 3 days. There is no proper reason for such inordinate delay. Original FIR was not furnished only xerox copy was produced, no documents produced regarding the complainant having taken treatment in Hassan and any reference for better treatment to hospital at Bangalore. OP is not liable to reimburse the medical expenses of Rs.37,033/- with interest and pay damages. <br /> <br /> 6. The defence version in complaint No.1533/2009 is OP rightly repudiated the claim as the complainant has not filled up the claim form in full. Leaving blanks in the claim form amounts to not properly filling the claim form. Complainant has not furnished documentary proof regarding medical treatment taken and also there is no proper description in the manner how the alleged accident took place. OP is not liable to reimburse the alleged medical expenses of Rs.37,817/- with interest and pay damages. Thus OP prayed to dismiss both the complaints. <br /> <br /> 7. The authorized signatory of PA Holder Company filed affidavit in order to substantiate the complaint averments. The Manager of OP filed the affidavit evidence.<br /> <br /> 8. Complainants filed written arguments. Arguments heard from complainants side. Taken as heard for OP. 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?<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 /> 9. We record our findings on above points: <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 /> 10. At the outset it is not at dispute that the complainants in both the complaint 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/- and the policy was valid on the date of accident. <br /> <br /> 11. In complaint No.1530/2009 the complainant sustained injury while traveling in car on 30.11.2008 within Hassan Traffic Police Jurisdiction. After taking the first aid treatment at Hassan, he was shifted to Prestine Hospital, Rajajinagar, Bangalore for better treatment and he has incurred medical expenses of Rs.37,033/-. The bills were submitted, OP repudiated the claim on the ground that the accident has taken place on 30.11.2008, but the same was reported to the police on 03.03.2009 i.e., after lapse of 3 months 3 days and there is no proper reason for such inordinate delay. Further it is stated that the complainant has not furnished the original FIR and there is no documents regarding any treatment taken at Hassan and referred for better treatment to Prestine Hospital at Bangalore. In our view OP has repudiated the claim on technical grounds. Merely because there is delay in lodging the complaint before the police with regard to the accident, it cannot be said that no accident has taken place and the complainant has not sustained injury. The medical records and other documents produced before the OP were sufficient to hold that the complainant has sustained injury in the accident. Even if no FIR was registered in respect of the accident, the same would not have been fatal to consider the claim of the complainant. The intimation and claim letter addressed to OP by M/s Swastik General and Health Care Services Pvt. Ltd., clearly goes to show that OP was informed about the injury sustained in the accident and the claim documents are being submitted in respect of the complainant. The receipt issued by Prestine Hospital Laboratory with regard to investigation charges goes to show that the total amount of Rs.4,320/- is charged; the copy of the discharge summary issued by Prestine Hospital reveals that the complainant was found sustained fracture base of 1st meacarpal right hand, contusion injury over right shoulder and lumbar spine, contusion of chest. The date of admission is shown as on 01.12.2008 and the date of surgery is shown as 02.12.2008 and the date of discharge 04.12.2008. The bill issued by Prestine Hospital is shows at Rs.32,713/-. The investigation charges bill is shown at Rs.4,320/- thus the total amount claimed by complainant is Rs.37,033/-. The complainant has submitted the xerox copy of the FIR; the original FIR was not submitted along with the claim documents. The fact that the details of the first aid taken at Hassan is not submitted with claim documents is not material. The accident in question has taken place around 11.30 p.m. on 30.11.2008, but in the information letter the date of accident is mentioned as 01.12.2008, the same cannot be taken to be material discrepancy. Under these circumstances we are of the view that OP was not justified in repudiating the claim. The complainant is entitled for reimbursement to medical expenses to the tune of Rs.37,033/-. The repudiation of the claim without valid grounds is deficiency in service on the part of the OP. <br /> <br /> 12. In complaint No.1533/2009 the complainant met with industrial accident on 24.04.2008 and suffered fracture of right leg. After taking the first aid treatment at Bidadi he was referred for further treatment to Bangalore. The complainant claimed total medical expenses to an extent of Rs.37,817/-. OP repudiated the claim on the ground that the complainant has not filled up the claim form in full and he has not furnished the documentary proof regarding the treatment taken at Bidadi. The date of accident is left blank in the intimation letter the nature of accident is not clear and there is no description of how the accident occurred. It may be noted that the complainant was working in M/s Crystal Granite and Marble Pvt. Ltd., as a worker. From the affidavit evidence it becomes clear that during the course of work he sustained fracture of right leg on 24.04.2008. The intimation and claim letter given by M/s Swastik General & Health Care Services Pvt. Ltd., to OP on 02.07.2008 clearly mentioned the fact of the complainant having sustained injury and the claim documents being submitted. The discharge summary issued by Punasru Hospital clearly reveals that the complainant had sustained injury to right knee and he was admitted in the hospital on 25.04.2008 and he was discharged on 30.04.2008. The certificate dated 24.04.2008 issued by Dr. G.N. Chandrashekar of the Prashanthi Hospital, Bidadi reveals that the complainant being employee of Crystal Granite has sustained injury to right knee joint and he was treated as out patient and referred to Bangalore for further treatment on 24.04.2008. From these documents it becomes clear that OP was in a position to know the date of accident and nature of injury sustained and the medical expenses incurred. The bill issued by Punasru Hospital dated 30.04.2008 is for Rs.29,200/-. The complainant has paid the said amount, the receipt has been produced. The complainant has not produced any other material to prove that he has incurred total expenses of Rs.37,817/-. However the complainant is entitled for the reimbursement of medical expenses to the tune of Rs.29,200/-. OP was not justified in repudiating the claim on technical grounds. Merely because M/s Swastik General and Health Care Services Pvt. Ltd., has paid the amounts to the complainants, OP cannot avoid its liability. Under these circumstances repudiating the claim on the part of the OP without valid grounds is deficiency in service on its part. The complainants are entitled for reimbursement of the medical expenses. Accordingly we proceed to pass the following: <br /> <br /> O R D E R<br /> <br /> Both the complaints allowed in part.<br /> <br /> 1. In complaint No.1530/2009 OP is directed to settle the claim of the complainant for a sum of Rs.37,033/- and pay litigation cost of Rs.500/- to the complainant.<br /> <br /> 2. In complaint No.1533/2009 OP is directed to settle the claim of the complainant for a sum of Rs.29,200/- 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 /> This original order shall be kept in the file of the complaint No.1530/2009 and a copy of it shall be placed in complaint No.1533/2009.<br /> <br /> Send the copy of this order to both the parties free of 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 11th day of November 2010.) <br /> <br /> <br /> <br /> PRESIDENT<br /> <br /> <br /> MEMBER MEMBER <br /> <br /> <br /> Snm:<br /> <br />