COMPLAINT FILED: 31-07-2009 <br /> DISPOSED ON: 06-02-2010<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> 6TH FEBRUARY 2010<br /> <br /> PRESENT :-SRI. B.S.REDDY PRESIDENT <br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI.A.MUNIYAPPA MEMBER <br /> COMPLAINT NO.1826/2009<br /> <br /> <br /> COMPLAINANT <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> B.Usha Devi<br /> W/o.Late Vasudeva Murthy,<br /> Aged about 46 Years,<br /> Residing at #842,6th Main Road,<br /> West of Chord Road, 2nd Stage, Mahalakshmipuram,<br /> Bangalore – 560 086.<br /> <br /> Advocate – Sri.A.Shivaram <br /> <br /> V/s.<br /> OPPOSITE PARTIES 1.Raksha TPA Pvt. Ltd.,<br /> #25, Ashirwad 1st Floor, <br /> 4th ‘B’ Cross, 29th Main,<br /> BTM Layout 2nd Stage,<br /> Bangalore – 560 076.<br /> <br /> 2.Managing Director,<br /> Raksha TPA Pvt. Ltd.,<br /> #25, Ashirwad 1st Floor, <br /> 4th ‘B’ Cross, 29th Main,<br /> BTM Layout 2nd Stage,<br /> Bangalore – 560 076.<br /> <br /> 3. The Divisional Manager<br /> The Oriental Insurance Company Ltd., #40/12, Swastik, <br /> Manandi Arcade, S.C.Road, Sheshdripuram, Bangalore-560020.<br /> <br /> <br /> O R D E R<br /> <br /> SRI. B.S.REDDY, PRESIDENT<br /> <br /> The complainant filed this complaint u/s. 12 of the C.P. Act of 1986 seeking direction against Opposite Parties (herein after called as OP) to reimburse an amount of Rs.43,080.75 towards the hospitalization and surgery and pay compensation of Rs.1,00,000/- with litigation cost of Rs.10,000/- on an allegations of deficiency in service on the part of the OPs.<br /> <br /> The case of the complainant to be stated in brief is that:-<br /> <br /> 2. OP1 is the company engaged in the business of insurance and work as agents for OP3 insurance company, OP2 is the Managing Director of OP1. The complainant availed individual medi-claim policy from OP3 through OP1 in the year 2007 valid for the period 2007-08. The said policy was renewed for the period 30-07-2008 to 29-07-2009, the sum insured is Rs.2,00,000/-. The complainant got admitted Bangalore Institute of Oncology as inpatient on 04-02-2009 to undergo surgery of “Carcinoma Thyroid”. After surgery she was discharged on 07-02-2009. After discharge from the hospital complainant submitted claim form, Original final bill with break up, original cash paid receipt, original detailed discharge summary, original pharmacy bills and prescriptions and investigation reports to the OP1 to reimburse the expenses incurred towards the surgery and hospitalization. OPs postponed to reimburse the claim amount on one pretext or other and finally a letter dated 21-03-2009 from OP1 was received stating their inability to conclude under policy coverage with the data available with them and sought the complainant to furnish the copies of indoor case papers from the hospital recorded during the hospitalization. The hospital authorities informed that the hospital records cannot be furnished to the out side agencies as per the policy of the hospital and assured that they can verify the records maintained by the hospital and copy down required details from the hospital records. The complainant informed the same to the OP; inspite of the same OP issued letter dated 21-03-2009 saying that the claim cannot be concluded and the amount paid towards the hospitalization and surgery cannot be released. The complainant got issued notice on 04-05-2009 claiming the amount with interest, OP has not replied for the same. OPs have committed breach of trust by not fulfilling the promises made by them at the time of issuing the individual Medi-claim Policy. The action of the OPs amounts to gross deficiency and negligence in service. Hence the complaint seeking the reliefs stated above. <br /> <br /> 3. Inspite of service of notice OP 1 & 2 failed to appear without any justifiable cause. Hence placed exparte.<br /> <br /> 4. On appearance OP3 filed version contending that complaint is not maintainable. Issue of policy and claim of the complainant is not disputed. It is stated that on receipt of intimation of claim, the insurer has to call for required documents to satisfy that a payable claim has arisen, within the purview of Rules and Regulations. No party can refuse to furnish the required details and documents called for by insurer. If any party considers calling for documents by insurer as deficiency in service, it is not correct and there is no necessity to traverse all averments of complaint in detail. Claim of complainant has not been repudiated. Important documents have been called for, to consider the claim. Excuse given by complainant that hospital is refusing to give records is not correct. All hospitals will give all records to the patient. Claim will be considered on the complainant furnishing required documents. There is no deficiency in service. Hence it is prayed to dismiss the complaint. <br /> <br /> 5. The complainant filed affidavit evidence to substantiate the complaint averments. Divisional Manager of OP3 filed affidavit by way of evidence. OP3 parties submitted written arguments.<br /> <br /> 6. After going through the pleadings, the documents produced and written arguments of OP3 and hearing on complainant side the following points that arise for our consideration are:-<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 /> <br /> <br /> 7. We record our findings on the above points are:-<br /> <br /> Point No.1:- Negative<br /> Point No.2:- Negative<br /> Point No.3:- As per final Order.<br /> <br /> <br /> <br /> <br /> R E A S O N S<br /> <br /> 8. It is not in dispute that the complainant availed the individual medi-claim policy No: 2008-815 from the Oriental Insurance Company Ltd., (OP3) through their agents OP1 in the year 2007 valid for the period 2007-2008. The said policy was renewed for the period 30-07-2008 to 29-07-2009 and the sum insured was Rs.2,00,000/-. The complainant claims that she was admitted to Bangalore Institute of Oncology as impatient on 04-02-2009 to under go surgery of “Carcinoma Thyroid”. After under going the surgery she was discharged on 07-02-2009 from the said hospital. She has produced original final bill, cash paid receipt, discharge summary, pharmacy bills and prescriptions with the claim form to reimburse the expenses incurred towards surgery and hospitalization. Inspite of producing all the documents OPs not settled the claim. Hence there is deficiency in service on the part of the OPs.<br /> <br /> 9. The complainant has produced document No.7 the letter dated 21-03-2009 addressed by OP3 in which, the complainant was informed that the claim has been made non tenable for the reason as they were unable to conclude under policy coverage with the data available. You were asked to produce copies of indoor case papers from hospital record during the hospitalization. On receiving cashless request from the hospital for the first time on 27-01-2009, to confirm the details given in the request; they have visited the hospital on 30-01-2009 and found that the patient not admitted at all and when verified the indoor case papers there were no entries made. So during both the time the documents were not produced. So the claim stands non payable. In the version filed OP3 has not denied fact of complainant having submitted the claim form with certain document but OP3 is seeking further documents i.e., copies of indoor case papers from hospital. The claim for reimbursement has not been repudiated by OP3. After the indoor case papers copies are produced OP3 will consider the claim. Therefore the act of OP3 seeking certain documents for considering the claim cannot be construed a deficiency in service on its part. <br /> <br /> 10. It is contended for the complainant that all the documents required are submitted with claim form on the basis of those documents OP3 can consider the claim and no specific documents are mentioned in the version which are required to be produced. <br /> <br /> In II (2008) CPJ 307 (NC) Dijabar Sahoo Vs. New India Assurance Company Limited – honourable National Commission at Para 3 observed that “it is not for the petitioner but the respondent –Insurance Company to decide which papers are necessary for settling the Insurance claim by it”. As per this observation it is not for the complainant to say that the documents already produced with claim form are sufficient to consider the claim. In the letter dated 21-03-2009 OP3 has clearly directed the complainant to produce copies of indoor case papers of hospital. We are unable to accept the contention that copies of indoor case papers will not be furnished by the hospital; as such complainant is unable to produce those documents. Every hospital maintains indoor case papers regarding admission and the treatment provided to the patients. It is bounden duty of the hospital to furnish the copies of those documents for the purpose of claiming reimbursement of medical expenses. The complainant has not produced any material to show that the hospital authority have refused to furnish the copies of indoor case papers. Under these circumstances we are of the view that the complainant failed to prove that there is deficiency in service on the part of the OP3. In view of the same complainant is not entitled to the reliefs claimed. Accordingly we proceed to pass the following :-<br /> <br /> O R D E R<br /> <br /> The complaint filed by the complainant is dismissed. However the complainant is at liberty to produce the copies of indoor case papers of the hospital as directed in the letter dated 21-03-2009 before the OP3. OP3 is directed to consider the claim within four weeks from the date of production of copies of indoor case papers. <br /> <br /> Considering the nature of dispute no order as to costs. <br /> <br /> Send copy of this order to both the parties free of costs. <br /> <br /> (Dictated to the Stenographer and typed in the computer and transcribed by her verified and corrected, and then pronounced in the Open Court by us on this the 6th day of February 2010.) <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> NRS<br /> <br />