<br /> COMPLAINT FILED: 27.08.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> <br /> 07th NOVEMBER 2008<br /> <br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT <br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI.A.MUNIYAPPA MEMBER <br /> <br /> COMPLAINT NO.1888/2008<br /> <br /> <br /> COMPLAINANT Mrs.Veeranathan,Aged 78 years,MF 1/11, HAL III Stage,New Thippasandra,Bangalore – 560 075.Advocate – Sri.S.R.Sree PrasadV/s.<br /> OPPOSITE PARTIES 1. The Branch Manager,Oriental Insurance Co. Ltd.,No.49, 2nd Floor, Jyothi Mahal St.Marks Road,Bangalore – 560 001.2. M/s. Raksha TPA (P) Ltd.,25, 4th B Cross, BTM Layout,Bangalore – 560 076.Advocate – Sri.V.Shri Hari Naidu<br /> <br /> O R D E R<br /> <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 pay a compensation of Rs.1,50,000/- and for such other relief’s 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 /> <br /> Complainant son has taken a group mediclaim policy from OP, which was valid from 25.03.2008 to 24.03.2009. The sum insured towards the medical expenses is to the tune of Rs.4,00,000/-. Complainant being the mother is a beneficiary under the said policy. In the month of May 2008 complainant approached St. Philominas Hospital, Bangalore for Pathological ailment. She was treated accordingly, she incurred as expenses of Rs.1,23,000/- made a claim to OP. OP reimbursed the said expenses. Again on 28.06.2008 she developed the same problem and went to the said hospital for the treatment. She was inpatient from 28.06.2008 to 12.07.2008, she was subjected to many more tests and examinations. Hospital raised the bill to the tune of Rs.75,000/- and that amount is paid by her son. There after they made a claim to OP to reimburse the said expenses. Unfortunately OP repudiated the said claim under the guise that it is hit by exclusion clause.4 of the policy. The repudiation is unjust and improper. The repeated requests and demands made by the complainants to OP went in futile. Thus she felt deficiency in service on the part of the OP. For no fault of her, she is made to suffer both mental agony and financial loss. Under the circumstances she is advised to file this complaint and sought for the reliefs accordingly.<br /> <br /> 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP they did settle the earlier claim for Rs.1,23,000/-, complainant want to take the undue advantage of the said settlement. Actually there was no need for the complainant to visit the hospital for the alleged Pathological ailment get herself admitted as an inpatient. The said treatment would have been conservatively taken in the house. The so called treatment taken by the complainant is covered under the exclusion clause 4.10 of the policy. As the claim of the complainant is not fair and honest, it was repudiated. That act of the OP is just and proper, it can’t be termed as deficiency in service. 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 has also filed the affidavit evidence and produced the documents. 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 <br /> the OP?<br /> <br /> Point No. 2 :- If so, whether the complainant is <br /> entitled for the relief’s now claimed?<br /> <br /> Point No. 3 :- To what Order?<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. At the outset it is not at dispute that the son of the complainant has taken a group mediclaim policy from OP.1, which was valid from 25.03.2008 to 24.03.2009. The sum insured towards the medical expenses is Rs.4,00,000/-. Complainant is the beneficiary under the said policy. It is also not at dispute that during the month of May 2008 when complainant took treatment at St.Philominas Hospital and incurred an expenses of Rs.1,23,000/-, it was promptly reimbursed by the OP. Subsequently there to that is on 28.06.2008 complainant developed the said acute pathological problem and she was again admitted as an inpatient in the said hospital from 28.06.2008 to 12.07.2008 and she was subjected to various tests and examinations and the proper treatment was given. Documents to that effect are produced.<br /> <br /> 7. It is further contended by the complainant that she has incurred an expenses of Rs.75,000/- for the said treatment which was later on paid by her son. Then they made claim to OP. Unfortunately OP repudiated the said claim under the guise of exclusion clause 4.10 of the policy. Repudiation letter, policy copy are produced. Now it is the grievance of the complainant that as she had acute pathological problem the doctors who treated her thought it fit to admit her as inpatient and treat her. It is the choice and discretion of the doctors to take a decision whether the said kind of treatment can be given at home conservatively or she should be admitted in the hospital for the examination and the treatment. OP can’t question the same. Hence for this simple reason the defence set out by the OP that complainant ought not to have got admitted as inpatient and she would have taken the treatment at home rather does not hold much force.<br /> <br /> 8. If there was no need for admitting the complainant as inpatient for the treatment, we don’t think in the ordinary course of time the doctors of St. Philominsa Hospital admitted the complainant as inpatient. In addition to that that act of the said doctors is not challenged by the OP by producing some rebuttal evidence through an expert that the ailment suffered by the complainant can be conservatively treated at home instead of admitting as inpatient in the hospital. So in absence of such proof the bare and vague defence set out by the OP rather appears to be baseless.<br /> <br /> 9. We have considered the contents of the undisputed documents and the pleadings, we are satisfied that the complainant is able to establish the deficiency in service on the part of the OP. The repudiation on the face of it appears to be unjust and improper, without due application of the mind. For no fault of the complainant she was made to suffer both mental agony and financial loss. Under such circumstances she is entitled for the relief to some extent. Of course complainant has claimed a compensation of Rs.1,50,000/-, for that claim there is no basis. In our view justice will be met by directing the OP to settle the said medical expenses for Rs.75,000/- and pay some nominal compensation and litigation cost. With these reasons we answer point Nos.1 & 2 accordingly and proceed to pass the following: <br /> <br /> O R D E R<br /> <br /> The complaint is allowed in part. OP is directed to reimburse the medical expenses of Rs.75,000/- and pay a compensation of Rs.5,000/- and litigation cost of Rs.1,000/- to the complainant.<br /> <br /> This order is to be complied within four weeks from the date of its communication.<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 07th day of November 2008.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> <br /> Vln* <br /> <br /> <br />