COMPLAINT FILED: 30.01.2009<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> 18th APRIL 2009<br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT<br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI. A. MUNIYAPPA MEMBER <br /> <br /> COMPLAINT NO. 267/2009<br /> <br /> <br /> COMPLAINANT Sri. C. Chikkanna,<br /> S/o. Sri. Channappa,<br /> Aged about 33 years,<br /> Residing at No. 526,<br /> 2nd Floor, 1st Main,<br /> 8th Cross, Maruthi Nagar,<br /> Bangalore – 560 026.<br /> <br /> <br /> V/s.<br /> <br /> <br /> OPPOSITE PARTY M/s. Star Health and Allied Insurance Co. Ltd.,<br /> No. 2/1, 2nd Floor,<br /> “Trikuta”, 8th Main Road,<br /> Sampangiramanagar,<br /> Bangalore – 560 027.<br /> Rep. by it’s Manager<br /> Sri. Sachin.<br /> <br /> <br /> Advocate (Ravi S. Samprathi)<br /> <br /> <br /> O R D E R<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 reimburse the medical expenses of Rs.12,728/- and pay a compensation of Rs.50,000/- and for such other reliefs 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 /> Complainant has taken health insurance policy from the OP. His father and mother are the beneficiaries under the said policy. The mother of the complainant Smt. Chikka Hanumakka was admitted at Gayathri Hospital, Bangalore for treatment. The hospital raised the bill for Rs.8,368/-. Complainant submitted the claim to the OP, OP settled the bill only for Rs.7,188/- without assigning any reason Rs.1,278/- is rejected. Thereafter the father of the complainant Channappa was admitted to the said hospital with some breathing problem, general weakness. The hospital treated his father and discharged him and raised the bill for Rs.11,450/-. When complainant made the claim OP repudiated the claim on flimsy reason and grounds on 05.01.2009. The repeated requests and demands made by the complainant to settle the said medical bills, went in futile. Thus he felt the deficiency in service on the part of the OP. Under the circumstances he is advised to file this complaint and sought for the relief accordingly.<br /> <br /> 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP complainant is bound by the terms and conditions of medi-classic policy which was inforce from 30.01.2008 to 29.01.2009. With regard to the medical bill submitted by the complainant about the hospitalization of his mother it was settled for Rs.7,188/-, it is paid directly to the hospital. As regards the bill raised with respect to Sri. Channappa OP is not obliged to honour the same because the treatment taken by the father of the complainant is for pre-existing disease, which comes under the exclusion clause. On the receipt of the claim OP got verified its genuineness and on going through the discharge summary and after obtaining the opinion of panel of doctors repudiated the said claim. There is no deficiency in service as alleged. The 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 the 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 the OP?<br /> <br /> Point No. 2 :- If so, whether the complainant is <br /> entitled for the reliefs now claimed?<br /> <br /> Point No. 3 :- To what Order?<br /> <br /> <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 complainant has taken medi-classic policy from OP which was inforce from 30.01.2008 to 29.01.2009. His father and mother are the beneficiaries under the said medi-classic policy covered by the OP. The fact that the mother of the complainant Smt. Chikka Hanumakka took treatment at Gayathri Hospital is not at dispute and OP settled the said bills for Rs.7,188/- as against Rs.8,368/- claimed by the complainant. It is contended by the OP that on thorough verification of the medical records and the documents as per their commitment under policy rules and conditions they have settled the bill as full and final. Complainant accepted the same, that amount is paid directly to the hospital. We find there is some justification in the contention of the OP in that regard.<br /> <br /> 7. It is further contended by the complainant that his father Sri. Channappa was also admitted in the said hospital with a breathing problem and general weakness, as he was suffering from cough and breathlessness, hospital after treating him raised the bill for Rs.11,450/-. The discharge summary, records, bills are produced. When complainant submitted the said bill for reimbursement, OP repudiated the same on 05.01.2009. The father of the complainant was admitted on 02.01.2009. The reason assigned by the OP is that the said treatment is taken for pre-existing disease.<br /> <br /> 8. We have gone through the documents produced by the litigating parties, there is no proof that the father of the complainant had any pre-existing disease with regard to the COPD. There is no proof that he has taken the treatment for the said ailment earlier to 02.01.2009 and he was aware of the same. OP says that it has referred the hospital records and discharge summary to panel of its doctors asserting their opinion, then repudiated the claim. Unfortunately the affidavit of the said panel of doctors who gave opinion is not filed. Under such circumstances basically there is no proof that the father of the complainant was suffering from COPD and it is within his knowledge and the treatment taken is for pre-existing disease. The burden is on the OP to establish and prove that the said treatment is taken for pre-existing disease. In our view OP failed in that regard. Hence for this simple reason the repudiation made by the OP appears to be without due application of mind, unjust and improper. We are satisfied that the complainant is able to prove the deficiency in service on the part of the OP.<br /> <br /> 9. The evidence of the complainant which finds full corroboration with the contents of the undisputed documents appears to be very much natural, cogent and consistent. There is nothing to discard his sworn testimony. Once when the complainant’s parents are the beneficiaries under the said policy, there is an obligation on the part of the OP to reimburse the said medical expenses. The reasons assigned with regard to repudiation are not sound. The hostile attitude of the OP must have naturally caused both mental agony and financial loss to the complainant, that too for no fault of his. In our view the justice will be met by directing the OP to settle the bill with respect to the father of the complainant and pay a litigation cost. Of course the claim of compensation of Rs.50,000/- has no basis. With these reasons we answer point nos.1 and 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 settle the medical bills for Rs.11,450/- with respect to the expenses incurred by the father of the complainant in taking treatment at Gayathri Hospital and pay the same to the complainant along with a litigation cost of Rs.500/-. This order is to be complied within 4 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 18th day of April 2009.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> p.n.g. <br /> <br />