Date of Filing: 17/10/2011

        Date of Order: 20/12/2011

BEFORE THE I ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE -  20

Dated:  20^th DAY OF DECEMBER 2011

PRESENT

SRI.H.V.RAMACHANDRA RAO,B.Sc.,B.L., PRESIDENT

SRI.KESHAV RAO PATIL, B.COM., M.A., LL.B., PGDPR, MEMBER

SMT.NIVEDITHA .J, B.SC.,LLB., MEMBER

COMPLAINT NO.1895 OF 2011

Mr.K.Rajiv,

Proprietor of M/s. Mark

Equipment and Service,

No.201, ‘Ullas Apartments,

8^th Main, Malleswaram,

Bangalore-560 003.

(Rep. by Sri.W.T.Prakash Kumar, Advocate)                         ….  Complainant.

V/s

1) Star Health And Allied Insurance

Company Limited, Corporate Office,

No.1, New Tank Street, Valluvarkottam

High Road, Nungambakkam,

Chennai-600 034.

Rep. by its Managing Director.

2) Star Health and Allied Insurance

Company Limited, Indra Arcade,

No.81, 1^st Floor, Dr.Rajkumar Road,

Rajajinagar 3^rd Stage, Bangalore-21.

Rep. by its Branch Manager.

(Rep. by Sri.V.P.Venkatapathi, Advocate)                           …. Opposite Parties.

BY SRI. H.V.RAMACHANDRA RAO, PRESIDENT

-: ORDER:-

The brief antecedents that led to the filing of the complainant U/s 12 of the Consumer Protection Act seeking direction to the Opposite Parties to pay Rs.2,25,900/-, are necessary:-

The complainant had obtained “Family Health Optima Insurance Policy” along with accident care policy schedule-individual, from the opposite parties bearing No. P/141123/01/2011/008556 and the policy was in force between 02.03.2011 to 01.03.2012.  The son of the complainant Atul B.R., after consultation with Dr.B.V.Raghunandan of Primary Medicare Centre was admitted in the said hospital on 19.05.2011.  The said son has undergone medical examination, even the representative of the opposite parties had visited the hospital and assessed the condition of the son and gave a report to the opposite parties.  The treatment was approved by the opposite parties with respect to left inguinal hernia.  On 19.05.2011 and the son was operated for left inguinal hernia.  The complainant had incurred an expenses of Rs.25,900/-.  On 19.05.2011 the opposite parties has sent an e-mail stating that his claim was rejected.  This is unfair trade practice and deficiency in service hence the complaint.

2.       In brief the version of the opposite parties are:-

          The complainant obtaining the insurance policy, its validity are all admitted.  As per the medical team report the ailment was pre-existing and not disclosed at the time of obtaining the policy.  Hence the claim for cashless treatment was rejected and the complainant was asked to produce the original documents along with the claim form which was sent for claim evaluation.  Hence the claim is premature.  All the allegations to the contrary are denied.

3.       To substantiate their respective cases, the parties have filed their respective affidavits.  The complainant has also filed the documents.  The arguments were heard.

4.       The points that arise for our consideration are:-

:- POINTS:-

1. Whether the complaint is premature?
2. What Order?

5.       Our findings are:-

Point (A) & (B):        As per the final Order

                             for the following:- 

-:REASONS:-

Point A & B:-

6.       Reading the pleadings in conjunction with the affidavits and documents on record, it is an admitted fact that the complainant had obtained “Family Health Optima Insurance Policy” along with accident care policy schedule-individual, from the opposite parties bearing No. P/141123/01/2011/008556 and it was valid during the period in question.  It is also an admitted fact that the complainant’s son had gone to the Primary Medicare Centre on 17.05.2011 certain tests were conducted and he was operated on 19.05.2011 for Left Inguinal Hernia and the complainant has spent in that regard the sum of Rs.25,900/-.

7.       It is also an admitted fact that in this regard the representative of the opposite parties have gone to the son of the complainant while he was in hospital they have enquired and assessed the matter.  On 19.05.2011 the opposite parties have denied the payment regarding cashless facility and they wanted the documents so that they can scrutinize and submit accordingly.  This has been considered by the complainant as repudiation of the claim and filed the complaint before this Forum.  During the course of the arguments the learned counsel for the opposite parties fairly stated that if the documents are sent to the opposite parties they will verify and pass appropriate orders in the matter.  Instead of sending it to opposite party if we handover all the records which has been furnished by the complainant to the counsel for the opposite parties and the learned counsel can send it to the opposite party directing opposite parties within a particular period to pass an appropriate order we think that will meet the ends of justice.  Hence instead of dismissing the complaint though it is premature we pass the following:-

ORDER

1.       The complaint is Disposed- off.

2.       The records furnished by the complainant in the list dated 20.12.2011 at serial No.3 that is marked as Exhibit - C-3 to C-16 are delivered to the counsel for the opposite parties, who has to send it to the opposite parties and the opposite parties shall process the claim and pass an appropriate order within 30 days from the date of this order.  If the complainant is aggrieved by the orders that may be passed by opposite parties he can approach this Forum again. 

3.       Return the extra sets filed by the parties to the concerned as under Regulation 20(3) of the Consumer’s Protection Regulation 2005.

4.       Send a copy of this order to both parties free of costs, immediately.

(Dictated to the Stenographer, transcribed and typed by him, corrected and then pronounced by us in the Open Forum on this the 20^th Day of December 2011)

MEMBER                                             MEMBER                                PRESIDENT