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Advocate J.S.Kulkarni for the complainant
Advocate S.G.Jogwadikar for the Opponent No.1 and 2.
Opponent No.3 exparte
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Per- Hon’ble Shri. V. P. Utpat, President
:- JUDGMENT :-
Date 23/08/2013
This complaint is filed by consumer against the Insurance Company and the Health Care Co. for deficiency in service u/s 12 of the Consumer Protection Act, 1986. Brief facts are as follows-
[1] Complainant is the employee of Cholamandalam General Insurance Co. which has provided the Group Insurance Scheme for its employees through the Opponent Nos.1 and 2. Opponent No.3 is the Health Care Private Ltd. Co. As per the said scheme the complainant and his family members are covered. The tenure of the insurance policy was from 1/5/2010 to 30/4/2011. On 21/1/2011 the wife of the complainant delivered baby girl which was suffering from Duodenal Dilatation since birth. Wife of the complainant was admitted in Bharati Hospital and operated in the said hospital. Complainant had spent Rs.36,040/- including the final bill of Rs.22,255/- for the medical treatment of his wife and newly born child. As per the terms and conditions of the policy the newly born child was also covered. But the Opponents denied to settle the claim of the complainant by stating that newly born child is not covered and the opponents have settled the claim at meager amount. The Opponents have not settled the claim as per the demand and thereby caused deficiency in service. Hence complainant has prayed for directing them to pay the expenses incurred by the complainant for the medical treatment of his family members. He has also asked compensation for mental and physical sufferings as well as cost of proceeding.
[2] Opponent Nos. 1 and 2 resisted the claim by filing written statement in which it has flatly denied that there is deficiency in service on the part of the Opponents. It has also contended that this Forum has no jurisdiction to entertain the complaint as there are no relations between the parties as consumer and service provider. It is also contended that the Opponents have settled the claim of the complainant to the tune of Rs.4057.56 and it has never denied the claim of the complainant. There is no cause of action and complaint deserves to be dismissed. The claim as regards compensation for mental and physical harassment as well as cost of the litigation is also denied by the Opponents. The Opponent No.3 did not contest the claim.
[3] After scrutinizing the documentary evidence, affidavits of both parties and hearing the argument of both counsel following points arise for my determination. The points, findings and reasons thereon are as follows-
Sr.No. | POINTS | FINDINGS |
1 | Whether complainant has proved that Opponents have caused deficiency in service by not settling the claim as per the demand ? | In the affirmative |
2 | What order ? | Complaint is allowed. |
Reasons
As to the Point Nos. 1 and 2-
It is not in dispute that the complainant is employee of Cholamandalam General Insurance Co. which has provided Group Insurance Scheme for their employees and the family members of the employees are also covered under the said scheme. It is also not in dispute that the policy was valid on the date of medical treatment taken by the wife as well as newly born child of the complainant. The opponents have not disputed the medical expenses which were incurred by the complainant for the treatment of his family members. The claim of Rs.36,040/- is supported by the documentary evidence such as bills issued by the concerned hospital and medical store. In these circumstances I held that the complainant has established that he had spent that much amount for the medical treatment of his wife and child. The dispute between the parties is as regards coverage of newly born child. It reveals from the terms and conditions of the policy which are produced on behalf of the complainant that the newly born child is also covered under the said policy. As the policy was valid on the date of medical treatment the newly born child was covered by the policy legitimate inference can be drawn that opponents have wrongly repudiated the claim of the complainant and thereby caused deficiency in service. Hence I answer point No.1 in the affirmative. The Opponents have refused to pay insurance claim without any sufficient cause. Hence the opponents are liable to pay compensation for deficiency in service to the tune of Rs.5,000/-, for mental and physical harassment to the tune of Rs.3,000/- and cost of litigation upto Rs.2,000/-. In all complainant is entitled to receive Rs.46,040/-.
I answer the points accordingly and pass the following order-
:- ORDER :-
1. Complaint is partly allowed.
2. It is hereby declared that the opponents have caused deficiency in service by wrongly repudiating the claim of the complainant.
3. Opponents are jointly and severally directed to pay sum of Rs.46,040/- to the complainant within six weeks from the date of receipt of copy of order.
4. Both parties are directed to collect the sets which are provided for the Hon’ble Members.
Copy of order be supplied to both the parties free of cost.
Place- Pune
Date – 23/08/2013
[S. M. Kumbhar] [V. P. Utpat]
Member President
