BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)

28^TH DAY OF DECEMBER 2015

O R D E R

SRI.P.V.SINGRI, PRESIDENT

This complaint is filed by the complainant under Section 12 of Consumer Protection Act, 1986 against Opposite Parties (herein after referred as OPs) claiming mediclaim amount of Rs.26,470/- from the OPs together with interest and litigation cost.

2. The brief averments made in the complaint are as under:

The complainant is a holder of mediclaim policy bearing No.421403/48/2014/1280 issued by OP-2.  The complainant underwent an Inguinal Hernia repair (operation) on 05.04.2014 at Bowring and Lady Curzon Hospital.  The complainant was an indoor patient and was discharged on 11.04.2014.  The complainant thereafter submitted claim form dated 21.04.2014 claiming reimbursement of Rs.26,470/- together with necessary enclosures.  The said mediclaim was sent to OP-1 for its onward transmission to OP-2.  Subsequently, the claim form was resubmitted with necessary corrections as demanded by the OPs on 24.04.2014.  The OPs failed to reimburse the said claim amount despite sufficient time and opportunity given. Thereafter the complainant registered a complaint with IRDA Grievances Cell.  Even thereafter the OPs failed to pay him the entire claim amount.  The complainant later came to know from OP-2 that a sum of Rs.432/- has been disallowed and his claim is under process.  The complainant immediately sent a mail to OP-2 on 28.05.2014 for verification.  However, he did not receive any response till the date of filing the complaint.

3. For the aforesaid reasons, the complainant prays for an order directing the OPs to pay him his entire claim amount of Rs.26,470/- together with interest and cost of litigation.

4. Though OP-1, entered appearance through one of their officer, but failed to file any version.

5. OP 2 in response to the notice issued, appeared through their Advocate and filed their version contending in brief, as under:-

It is true that the complainant has taken a mediclaim policy from the OP-2 Company.  The complainant having undergone an operation for Inguinal Hernia repair submitted claim in a sum of Rs.26,470/- towards expenses incurred for the operation.  The claim was processed/scrutinized by OP-1 who is an IRDA licensed Third party Administrator (TPA) and claim settlement shall be of OP-2.  On scrutiny of the papers submitted by the complainant out of claim amount of Rs.26,470/- the OP-1 recommended for settlement of claim amount of Rs.26,037/- and disallowed of Rs.433/-.  This was informed to the complainant.  Based on the recommendation of the OP-1, OP-2 approved claim for Rs.26,037/- and the same was intimated to the complainant and he was asked to submit a cancelled cheque with bank account details to OP-1 to enable to settle the claim.  The disallowed amount includes Hospital discount charges of Rs.50/-, Hospital discount charges of Rs.120/-, Betadine charges of Rs.88/-, registration charges of Rs.50/- and Rs.125/- towards non-availability of bills, thus in all amounting to Rs.433/-. 

6. The complainant is entitled to a sum of Rs.26,037/- only towards settlement of claim and deduction of Rs.433/- was in accordance with the terms of mediclaim policy and as per the exclusion clause (4).  The complainant has failed to send a cancelled cheque with bank details to OP, despite repeated enquiries to enable it to settle the claim.   The claim of the complainant has been provided in accordance with the mediclaim policy and the complaint filed by the complainant is devoid of any merits. 

7. For the aforesaid reasons OP-2 prays for dismissal of the complaint.

8. On the rival contention of both the parties, the points that arises for our determination are as under:

1. Whether, the complainant proves deficiency in service on the part of the OPs as alleged in the complaint?

2. If So, what relief or order the complainant is entitled to?

9. After OP-2 filed their version, the complainant was called upon to file his affidavit evidence and accordingly he filed his affidavit evidence, in lieu of oral evidence reiterating the allegations made in the complaint. OP-2 filed the affidavit evidence of Sri.R.S.Arasu, Deputy Manager, in support of averments made in their version.  The complainant filed his written arguments also.

10. Perused the allegation made in the complaint, averments made in the version filed by OP-2, the sworn testimony of both the parties, written arguments filed by the complainant and various documents produced by both the parties.  Heard the oral arguments advanced by complainant as well as the learned advocate for OP-2.

11. Our answer to the above points:

12. POINT NO.1: OP-2 in their version admitted that the complainant is a holder of mediclaim policy bearing No.421403/48/2014/1280 and also admitted the claim submitted by complainant in a sum of Rs.26,470/- for having undergone operation and treatment for Inguinal Hernia repair at Bowring and Lady Curzon Hospital, Bangalore, OP-2 restrict their liability to Rs.26,037/- and contend that the complainant is not entitled to a sum of Rs.433/- as the same is not allowed in terms of the mediclaim policy.  Now, the dispute is regarding the disallowed sum of Rs.433/- out of claim amount of Rs.26,470/- and also non-payment of even the admitted amount by OP-2 till this date. 

13.  OP-2 contended that the complainant is not entitled to Rs.50/- and Rs.120/- spent towards Hospital discount charges, Rs.88/- spent towards purchase of Betadine medicine, Rs.50/- spent towards registration charges and Rs.125/- towards non-availability of necessary bill.  The learned advocate for the OP-2 argued that the complainant is not entitled to above mentioned amount of Rs.433/- in pursuance of exclusion clause (4).  OP-2 has produced the Proforma copy of the mediclaim policy.  We perused the exclusion clause.  The learned advocate for OP referred to clause 4.10, 4.11, 4.14 and 4.17 and he highlighted clause 4.17 which provides that a policy holder is not entitled to any expenses incurred for all non-medical expenses including personal comfort and convenient items or services such as telephone, television, Aya/barber or beauty services, diet charges baby food, cosmetics, napkins, toiletry items  and also guest services and similar incidental expenses or services etc.  He also referring to clause 4.10, 4.11, 4.14 submitted that OP-2 is justified in disallowing the above mentioned amount and the same is in terms of policy documents.

14. We perused the above mentioned clauses referred to and we do not find any mention in any of these clause which disallows payment made towards hospital discount, medicine charges and registration charges.  We do not find anything in the copy of the receipts produced by the complainant that he has not paid the hospital discount charges as mentioned therein.  The complainant has subsequently provided the necessary receipt for Rs.125/- also.  The learned advocate for OP-2 submitted that the complainant is not entitled for Rs.88/- for purchase of Betadine medicine. The complainant contended that the Betadine medicine which he has purchased for Rs.88/- is used for cleaning post operation wound and the doctor use the said medicine in case of every operation and it is absolutely necessary to purchase the said medicine.  We do not find anything in the exclusion clause which disallows the money spent for a medicine which is essential in a surgical procedure.  We also do not find anything in the exclusion clause disallowing the payment made for registration charges.  Though, it is stated by OP that a sum of Rs.50/- and Rs.120/- has not been paid towards hospital discount, but the fact remains that the complainant has paid the said amount for which a receipt has been issued by the hospital.  We also do not find any provision in exclusion clause which disallows such payment made by a policy holder.  Therefore, we are of the opinion that OP-2 is not at all justified in disallowing the sum of Rs.433/- out of Rs.26,470/- claim made by the complainant.

15. The learned advocate for the OP-2 submitted that the OP-2 was ever ready to pay sum of Rs.26,037/- to the complainant on his furnishing a cancelled cheque with his bank account details. He further submitted that since the complainant failed to furnish a cancelled cheque with his bank details, OP-2 could not pay him the said sum of Rs.26,037/-.  The complainant contended that he is not supposed to disclose his bank details to OP-1, which is confidential.  Moreover, the terms and conditions of the policy doesn’t require/warrants a policy holder to disclose his bank account details for receiving the claim amount.  Therefore, we are of the opinion that OP-2 was not at all justified in not paying the admitted amount on the ground that the complainant has failed to send a cancelled cheque with bank account details.  The complainant is not obliged to disclose the bank details.  Nothing prevented OP-2 to send the said amount through a demand draft or a pay order.  Therefore, we are of the opinion that OP-2 is liable to pay interest at 12% per annum on the entire claim amount. 

16. We also noticed that there is an inordinate delay on the part of the OPs in settling the claim of the complainant.  The conduct of OPs certainly amounts to deficiency in service.  The conduct of OPs must have caused lot of inconvenience, hardship and mental agony to the complainant.  Therefore, we are of the opinion that apart from paying a sum of Rs.26,470/- together with interest at the rate of 12% per annum, the OPs are also liable to pay a compensation of Rs.5,000/- for deficiency in service on their part.  Accordingly, we answer Point No.1.

17. The order could not be passed within the stipulated time due to heavy pendency.  For the discussion made above we proceed to pass the following:

ORDER

1. The complaint filed by complainant under section 12 of the Consumer Protection Act, 1986 is allowed in part. 

2. OPs are hereby directed to pay a sum of Rs.26,470/- to the complainant together with interest at the rate of 12% per annum from the date of said amount was due till the date of realization.

3. Further OPs are directed to pay compensation of Rs.5,000/- to the complainant for deficiency in service on their part together with litigation cost of Rs.5,000/-.

4. OPs shall comply the order of this Forum within a period of four weeks from the date of communication.

5. Furnish free copy of this order to both the parties.

 (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 28^th day of December 2015)

MEMBER                                 MEMBER                            PRESIDENT

NRS* 

C.C.No.1128/2014

Witness examined on behalf of the complainant dated 28.10.2014

1. Sri.Niranjan Roy,

Witnesses examined on behalf of the OP 2 dated 30.01.2015

1. Sri.R.S.Arasu,

MEMBER                                 MEMBER                            PRESIDENT