BEFORE THE BANGALORE URBAN III ADDITIONAL DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION,

SHANTHINAGAR, BANGALORE–560027.

DATED THIS THE 26^th DAY OF FEBRUARY 2021

CONSUMER COMPLAINT NO.1265/2019

PRESENT:

Sri.K.S.Bilagi, B.com, M.A., LL.M.….  PRESIDENT

Smt.L.Mamatha, B.A., (Law), LL.B.….     MEMBER

Sri. M.B. Seena, B.A., (Law), LL.B.….       MEMBER

COMPLAINANT:

Smt.Radhika Mehta,

W/o Dhanvanth Kumar,

Aged about 60 Years,

R/at No.3967, 19^th Cross Road,

III Main Road,

BSK II Stage,

Near post Office,

(Rep. by Sri.K.V.Lakshmanachar, Advocate)

V/s

OPPOSITE PARTIES

1. Tata AIG General Insurance Company Limited,
2.  

Tower ‘A’, Peninsula Business Park,

Ganpatrao Kadam Marg,

Off.Senapati Bapat Marg,

Lower Parel,

Rep by its Authorized Signatory.

2. TATA AIG General Insurance Signatory,

Having its Branch office at

Empire Hotel, 2^nd Floor,

J.P.and Devi Jambukeshwara Arcade,

69, Millers Road,

Written by SMT.L.MAMATHA, MEMBER

******

//ORDER//

1. This complaint has been filed under Section-12 of the Consumer Protection Act 1986 against Opposite Parties to pay a sum of Rs.2,79,852/- towards reimbursement of medical expenses spent by Complainant and towards hospitalization for kidney related ailment which are duly covered under the policy of insurance issued by the Opposite Party with interest at 24% p.a. and to grant compensation towards deficiency of service.

2. The case of the Complainant in brief is as under:-

The Complainant is the wife of Dhanvanth Kumar, who have obtained a Tata AIG Wellsurance Executive Policy bearing No.023538861703 covering the medical insurance of the Complainant.The policy was effective from 18.03.2018 to 17.03.2019 and same has been renewed from time to time.The policy covers of the insured in respect of the ailments mentioned in the policy and the benefits to which the insured is entitled under the said policy.The Complainant was admitted to NU Hospital, Padmanabanagar, Bangalore which is a Specialist in Urinary and Kidney Care-Transplantation Centre.On 10.07.2018 and the Complainant underwent cystoscopy and ureteric stenting and she was discharged on 16.07.2018.The total bill amount is Rs.1,22,552/-.After discharge made a claim with the Opposite Parties which is registered as No.0820889718A.The Complainant again readmitted on 07.10.2018 to 10.10.2018. The Complainant submitted claim form along with bills amounting Rs.2,10,000/- which was registered as claim No.0235388617.The Complainant is entitled to receive a sum of Rs.3,06,202/-.The Opposite Party has unreasonably denied the reimbursement of the medical expenses which the Complainant was duly entitled to and have paid only a sum of Rs.26,350/- towards the settlement of the entire claim made by the Complainant.The Opposite Party had paid only a part of the hospitalization charges by rejecting the remaining of the bills submitted by the Complainant along with the claim form amounts to breach of trust and deficiency of service on the part of Opposite Parties in not extending the benefits to which the Complainant is legally entitled under the policy. The Complainant issued a legal notice dt.21.01.2019 which is duly served on Opposite Parties and they replied the notice on 27.02.2019.Hence this complaint.

3. Despite receipt of notice with copy of complaint, the Opposite Parties failed to appear before this Commission and Opposite Parties have been placed ex-parte.

4. The Complainant has filed her affidavit evidence and produced some documents in support of her case which are marked as EX.P1 to P6.

5. Heard the arguments of the Complainant.
6. The points that arise for our consideration are:-

1. Whether the complainant proves deficiency of service on the part of the Opposite Parties ?
2. Whether the Complainant is entitle to the reliefs claimed in the complaint ?
3. What order ?

7. Our findings on the above points are:-

1. Point No.1       :- In the affirmative
2. Point No.2         :- Affirmative in part
3. Point No.3       :- As per final order

for the following;

:REASONS:

8. POINT NO.1:- Eventhough, the Opposite Parties have been placed ex-parte, it is the duty of this Commission to consider the case of the Complainant on merits.

9. The documents produced by the Complainant reveal that the Complainant’s husband have availed a Tata AIG Wellsurance Executive Policy bearing No.023538861703 covering the medical insurance of the Complainant and her son. The Policy was effective from 18.03.2018 to 17.03.2019 and the same has been renewed from time to time. The Complainant admitted at NU Hospital, Padmanabanagar, Bangalore on 10.07.2018 and discharged on 16.07.2018.  The bill amount is Rs.1,22,552/-.  After discharge, she made a claim with the Opposite Parties which is registered No.0820889718A again on 07.10.2018 admitted and discharged on 10.10.2018.  The 2^nd bill amount is Rs.2,10,000/- which was registered as claim No.0235388617.  Total bill amount of Rs.3,06,202/-.  The  Opposite Party paid Rs.26,350/- towards the settlement of the entire claim, but denied the reimbursement of the balance amount of Rs.2,79,852/- towards hospitalization charges is unreasonable. Due to this, the Complainant suffered a lot.  The Complainant requested Opposite Parties to resolve the issues.  But Opposite Parties not responded for the same.  On 21.01.2019 Complainant issued legal notice which is duly served.  On 27.02.2019, the Opposite Parties replied the notice to Complainant.  To substantiate this case, the Complainant filed her affidavit evidence reiterating the averments of complaint.  The Complainant produced the documents which are marked as EX.P1 to P6 which clearly show that the Opposite Parties failed to honour the claim of the Complainant.   Therefore evidence clearly goes to show that the Opposite Parties paid only Rs.26,350/-, but denied the balance payment without valid reason.  Opposite Parties neither responded nor resolved the issues.  If at all, the Opposite Parties render good service to the Complainant, the Opposite Parties would have appear and filed their version and filed evidence.  But Opposite Parties failed to appear.  Thereby, the Opposite Parties have impliedly admitted all the allegations made against them in the Complaint.  In this context, we may refer to the decision of Hon’ble National Commission reported in 2018 (1) CPR page No.325(NC) in Kotak Mahindra Limited old Prudential Life Insurance Limited V/s Dr.Nishi Gupta, wherein it is held that the non-filing of the written version amounts to admission of allegations made by the Complainant in the Consumer Complaint.  The oral and documentary evidence produced by the Complainant remained unchallenged.  Therefore, there is no reason to disbelieve the evidence of the Complainant.  Due to the deficient service of Opposite Parties, Complainant suffered mental agony and financial loss.  Inspite of repeated requests, the Opposite Parties never bothered to fulfill the demand of the Complainant.  This clearly shows that there is deficiency of service on the part of the Opposite Parties.  Hence, point No.1 answered affirmative and infavour of the Complainant.

10. POINT No.2 & 3:- In view of the finding recorded on the point No.1 holding in affirmative, the next aspect is to be considered about the relief to which the Complainant is entitled. 

11. The Complainant sought for refund of Rs.2,79,852/- with 24% interest p.a.  The claim of interest is not fully justified.  So we deem fit and proper to award Rs.2,79,852/- with Rs.25,000/- as compensation and Rs.5,000/- as cost of litigation to the Complainant.  The Complainant is not entitled to interest on this amount.  Accordingly, we answer point No.1 & 2 in accordingly infavour of Complainant and proceed to pass the following final order;
12.  

The complaint u/s 12 of Consumer Protection Act, 1986 is allowed in part holding that there is deficiency of service on the part of Opposite Parties. 

The Opposite Parties are directed to pay Rs.2,79,852/- and Rs.25,000/- as compensation to the Complainant.

The Opposite Parties are directed to pay Rs.5,000/- towards cost of litigation to the Complainant. If Opposite Parties failed to pay this amount within 45 days, the Opposite Parties shall pay 12% interest on Rs.2,79,852/- after expiry of 45 days till realization.

Supply free copy of this order to both the parties and return extra copies of the pleading and evidence to the Complainant.

 (Dictated to the Steno, typed by her, transcript corrected, revised and then pronounced by the open Forum on 26^th day of FEBRUARY 2021)

    (L.Mamatha)              (M.B.Seena)                  (K.S.Bilagi)

       MEMBER                  MEMBER                    PRESIDENT

//ANNEXURE//

Witness examined for the complainant side:

Smt.Radhika Mehta, who being the Complainant has filed her affidavit.

List of documents filed by the complainant:

1. Copy of the policy No.023538861703.
2. Copy of the bills of NU Hospital, Padmanabha Nagar Bengaluru.
3. Copy of discharge summary of NU Hospital.
4. Copy of the mail dt.09.08.2018.
5. Copy of the legal notice dt.21.01.2019.
6. Copy of the reply dt.27.02.2019.

Witness examined on behalf of the Opposite Party:

   -NIL

List of documents filed by the Opposite party:

-Nil-

(L.Mamatha)                 (M.B.Seena)               (K.S.Bilagi)

  MEMBER                      MEMBER                 PRESIDENT