Complaint filed on: 26-06-2010 <br /> Disposed on: 28-09-2010<br /> <br /> BEFORE THE BANGALORE IV ADDITIONAL DISTRICT <br /> CONSUMER DISPUTES REDRESSAL FORUM,<br /> BANGALORE URBAN DISTRICT, NO.8, SAHAKARA BHAVAN, CUNNINGHAM ROAD, BANGALORE – 560 052 <br /> <br /> C.C.No.1458/2010<br /> DATED THIS THE 28th SEPTEMBER 2010<br /> <br /> PRESENT<br /> <br /> SRI.D.KRISHNAPPA., PRESIDENT<br /> SRI.GANGANARASAIAH., MEMBER<br /> SMT. ANITA SHIVAKUMAR. K, MEMBER<br /> <br /> Complainant: - <br /> B.Usha Devi W/o. Late Vasudeva <br /> Murthy, aged about 46 years, <br /> Residing at # 842, 6th main road, <br /> West of Chord Road, 2nd stage, <br /> Mahalakshmipuram, <br /> Bangalore-86 <br /> <br /> <br /> V/s<br /> <br /> Opposite parties: - <br /> <br /> 1. RAKSHA TPA PVT. LTD, <br /> # 25, Ashirwad, 1st floor, <br /> 4th B Cross, 29th main, <br /> BTM Layout, 2nd stage,<br /> Bangalore-76<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-76<br /> 3. The Divisional Manager, <br /> The Oriental insurance Co. Ltd,, # 40/12, Swastik, <br /> Manandi Arcade, <br /> SC Road, Sheshadripuram,<br /> Bangalore-20. <br /> <br /> <br /> <br /> <br /> <br /> O R D E R<br /> <br /> SRI. D.KRISHNAPPA., PRESIDENT., <br /> <br /> The grievance of the complainant against the opposite parties [hereinafter called as OPs for short) in brief is that, she availed a mediclaim insurance policy from the 3rd OP, Ops No.1 and 2 are their agents acting as the third party administer to settle the insurance claim. That the policy limit was fixed for Rs.2,00,000/- and it was valid from 30-7-2008 to 29-7-2009. That she was suffering from “Carcinoma Thyroid” and was advised by the doctor of Bangalore Institute of Oncology to under go surgery and she under gone surgery as in-patient from 4-2-2009 to 7-2-2009 in the Bangalore Institute of Oncology. After she was discharged from the hospital, she made a claim with the 3rd OP, enclosing all original bills to reimburse her hospital expenditure. While she was under treatment, in order to reimburse the expenditure, she requested the 3rd OP to meet the hospital expenditure, but he did not do so. Therefore, she had to approach her brother to meet the hospital expenditure who after availing credit, under his credit card with interest at 47% per annum helped her to meet the hospital expenditure. Even thereafter also the Ops have failed to reimburse the medical expenditure. That she had earlier filed complaint in CC.1826/2009 before the district forum claiming reimbursement of Rs.43,080.75/- and also to award compensation. The district forum while dismissing the complaint gave liberty to her to claim afresh from the OPs by producing all necessary documents and directed the 3rd OP to consider her claim within four weeks from the date of production of in door case papers. But even then the Ops have failed to comply that order and even after issue of a legal notice also did not heed to reimburse and therefore has prayed for a direction to the Ops to reimburse her medical expenditure amounting to Rs.43,080-75 and to award compensation of Rs.1,00,000/- for mental agony hardship and also to award cost. <br /> <br /> 2. This forum had ordered notice to Ops No.2 and 3, as Ops No.1 and 2 are one and the same, OP No.2 remained absent, after service is set-exparte. OP No.3 has appeared and filed version and stated that the 2nd OP who is their agent is empowered to settle the claim arising under mediclaim policy or to repudiate her claim. That they have already intimated to 1st OP to decide the matter and also reminded them to dispose the claim of the complainant and the 3rd OP has enclosed a copy of a letter dated 21-5-2010 addressed to the 2nd OP in which the 3rd OP has requested the 2nd OP to consider the claim of the complainant for reimbursement by treating it has must urgent. <br /> <br /> 3. In the course of enquiry into the complaint, the complainant and the 3rd OP have filed their affidavit evidence reiterating what they have stated in their respective complaint and version. The complainant alongwith the complaint has produced a copy of the order passed by the District Forum in CC.No.1826/2009, copies of hospital records with a copy of legal notice she got issued to the Ops. The 3rd OP has produced a copy of the letter he had addressed to the 2nd OP. We have heard the counsel for the complainant. Since the 3rd OP and his advocate remained absent, they are taken as heard.<br /> <br /> 4. On the above materials following points for determination arise.<br /> 1. Whether the complainant proves that, the Ops No.2 and 3 have caused deficiency in their service in not reimbursing her medical expenditure?<br /> 2. To what reliefs, the complainant is entitled to?<br /> <br /> 5. Our findings are as under:<br /> Point no.1: In the affirmative<br /> Point no.2: See the final Order<br /> <br /> REASONS<br /> 6. Answer on Point No.1: As already referred to above, this is a second round of litigation initiated by the complainant for the same relief, as earlier complaint filed before this District forum came to be dismissed with a liberty to the complainant to produce necessary documents before the 3rd OP to consider the claim. The forum earlier had directed to the 3rd OP to consider the claim of the complainant within four weeks from the date of production of copies of indoor case paper, this order was passed on 6-2-2010. Thereafter, it is not in dispute that the complainant though had produced all the necessary documents, the Ops failed to take decision in one way or other but slept over the claim of the complainant and direction given by the forum in the earlier proceeding. <br /> <br /> 7. The 3rd OP is the insurance company who has issued insurance policy covering health risk of the complainant. The 2nd OP according to them is third party administrator who is empowered to process the claim papers and take a decision, The 3rd OP in the version and also affidavit evidence stated as if they have no role in the matter and they intimated the 2nd OP to decide the matter even by reminding then. The 3rd OP has even produced a copy of letter addressed to the 2nd OP in which this OP has categorically directed the 2nd OP by forwarding TPA claim with all hospital records with the opinion of their advocate for doing needful and take a decision in the matter as the matter must urgent but it looks that the 3rd OP after addressing a letter to OP No.2, but the OP kept quite and 2nd OP did not bother to look to the claim of the complainant and act upon the letter of the 3rd OP. We fail to understand this kind of irresponsible attitude of Ops No.2 & 3 and the accountability of these two parties to each other and to the insured, we are not convinced to accept that the 3rd OP the insurer is helpless in case of this type against the 2nd OP who is a third part administrator when he did not respond to the insurance company. OP No.3 also could not have kept quite that too when there is a direction by a legal authority under the Consumer Protection Act, in action of Ops No.2 and 3 and this disobedience of the direction of the forum speaks much about their indifference to the plight of the insured. <br /> <br /> 8. The complainant by producing copies of hospital bills claimed for reimbursement of Rs.43,080.75 and that amount is not disputed by any of the OPs. The 3rd OP who is contesting the complaint has not controverted or disputed the quantum of amount claimed by the complainant and her entitlement. It is not the case of any of these Ops that there was any lapse or latches on the part of the complainant in not complying their requirement. Therefore, we find from the undisputed fact that, there is sheer negligence and grave disobedience of direction of the district forum and deficiency in their service, as such the claim of the complainant which has remained undisputed and unquestioned needs to be allowed, in addition to ordering reimbursement of medical expenditure, we find this is as just case to impose punitive damages against Ops No.2 and 3 for their callous attitude and unjustifiable deficiency in their service. Besides this, we should also bear in mind that the complainant who is a widow has stated that she is depending upon the retirement benefit of her late husband could not meet hospital expenditure had to borrow from her brother who in turn adjusted money by drawing from his credit card by paying higher rate of interest. The object of insurance found to have bear defeated by these Ops, with this, we answer point no.1 in the affirmative and pass the following order:<br /> <br /> ORDER<br /> <br /> 1. Complaint is allowed. Ops No.2 and 3 are jointly and severally are held as liable and are directed to reimburse of Rs.43,080/-within 50 days from the date of this order. <br /> <br /> 2. Ops No.2 and 3 shall also jointly and severally pay punitive damages of Rs.50,000/- out of which Rs.40,000/- be paid to the complainant and balance for Rs.10,000/- be remitted to the legal aid account maintained by this forum. These amounts shall be paid within 50 days from the date of this order. Failing which, the Ops shall pay interest at 9% per annum from the date of this order till the date of payment. <br /> <br /> 3. Ops No.2 and 3 shall also pay cost of Rs.5000/- to the complainant. <br /> <br /> <br /> Dictated to the Stenographer, Got it transcribed and corrected, Pronounced on the Open Forum on this 28th September 2010.<br /> <br /> <br /> <br /> Member Member President<br />