BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM RAICHUR.
COMPLAINT NO. (DCFR) CC. 25/2012.
THIS THE 27th DAY OF AUGUST 2012.
P R E S E N T
1. Sri. Pampapathi B.sc.B.Lib. LLB PRESIDENT.
2. Sri. Gururaj, B.com.LLB. (Spl) MEMBER.
3. Smt. Pratibha Rani Hiremath,M.A. (Sanskrit) MEMBER.
*****
COMPLAINANT :- Sri. Ashok Kumar Bohra S/o. Fakar Chand Bohra,
Age: 60 years, Occ: Business, R/o. Mahaveer Chowk, Cloth Bazar, Raichur.
//VERSUS//
OPPOSITE PARTIES :- 1. The Branch Manager, National Insurance
Company Ltd., Branch Office, Lingasugur Road, Raichur.
2. The Regional Manager, MD India Health Care Services (TPA) Pvt. Ltd., Regional office, Bungalow No. 8, 9th Cross, Wilson Garden, Bangalore- 560027.
(Impled as per the order of the Hon’ble Court dt. 22-06-2012).
CLAIM : For pay an amount of Rs. 1,34,114/- in respect of medical expenses, under the policy bearing No. 604002/48/10/8500000050 along with interest and other benefits and also Rs. 1,00,000/- towards damages and cost.
Date of institution :- 29-03-12.
Notice served :- 19-04-12.
Date of disposal :- 27-08-12.
Complainant represented by Sri. Earanna, Advocate.
Opposite No. 1 represented by Sri. Vishwanath Pattanasetty, Advocate.
Opposite No-2 Ex-Parte.
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This case coming for final disposal before us, the Forum on considering the entire material and evidence placed on record by the parties passed the following.
JUDGEMENT
By Sri. Gururaj, Member:-
This is a complaint filed by complainant Sri. Ashok Kumar BohraK. against opposite Nos. 1 & 2 Insurance Company Ltd., U/sec. 12 of Consumer Protection Act for to pay an amount of Rs. 1,34,114/- in respect of medical expenses, under the policy bearing No. 604002/48/10/8500000050 along with interest and other benefits and also Rs. 1,00,000/- towards damages and cost.
2. The brief facts of the complainant’s case are that, spouse of complainant was suffering from ill-health and was admitted in Pune Hospital, and Research Center from 10-07-2010 to 11-07-2010 and further she was admitted in Sancheti Hospital, Pune on 11-07-2010 to 17-07-2010 and 14-10-2010 to 20-10-2010 for to get treatment to fracture (L) Femure lower and commuritte, and treatment was given during the operative period of the policy in question for which the complainant has spent for an amount of Rs. 1,34,114/-.
It is the further case of the complainant that, the sum assured of the policy is Rs. 2,50,000/- and under the said policy both complainant and his spouse (wife) . That immediately after treatment and payment of the medical expenses to the tune of Rs. 1,34,114/- the complainant filed the claim with all supportive medical bills through Development Officer of the opposite No-1. Accordingly, he has sent claim to the third party sell M/s. M.D. India Ltd., Bangalore for approval scrutiny from the opposite.
It is further case of the complainant that he has obtained the policy from opposite No-1 Branch and was also paid premium to the said opposite further he has raised question against the sending of the claim to the M/s. M.D. India Ltd., Bangalore and what was the understanding between the opposite and M.D. India ltd., Bangalore this was not made known to the complainant in the policy. Further, he has contended that, even inspite of several approaches to the opposite the opposite asked to send anther three sets of medical bills to TP Cell. Accordingly, the complainant on 02-08-2011 has complied the demands made by the opposite, despite having complied with all the statutory requirements for claims settlement and paying personal visit along with the letter of the opposite office on 22-10-2011, nothing is coming forward in the settlement. The complainant has got issued legal notice on 21-01-2012 but even inspite of this notice and several approaches opposites have not settled the claim of the complainant till this date, this attitude of the opposite amounts to deficiency in service on their part for which complainant has suffered lot of mental pain, agony and torture hence, demanded for the claim of Rs. 1,00,000/- for deficiency in service damages etc., along with medical expenditure i.e, claim amount of Rs. 1,13,114/- against the opposite.
3. Opposite Insurance Company appeared through its Advocate, filed written version. Subsequently opposite No-2 has been impleaded through order dt. 15-06-2012 on IA filed by the opposite No-1, accordingly, notice has been issued but even inspite of service of the notice by RPAD the opposite No-2 remained absent on 12-07-2012 when the date of hearing was fixed but on that day the court has been boycotted by the advocates hence, the case is posted on 13-07-2012 for the appearance of opposite No-2 but on that day also he remained absent, hence he has been placed Ex-parte.
The opposite No-1 Insurance Company filed its written version contending that, if anybody wants to claim under medical policy immediately after the admit in the hospital within 24 hours it should be intimated to the TPA of the company or claims should be submitted after the discharge i.e, 20-10-2010, within one month from the date of discharge as per the condition mentioned in the policy at 5.2 of the terms and conditions, but the complainant spouse was submitted in the month of December-2010 as per they say which is after stipulated period and the bills and other documents which are submitted by the complainant to TPA are all created, concocted one. The complainant is in the habit of claiming false claim against this opposite for the same illness from the same hospital which is situated out of state made created documents and claiming under said illness twice in a year to defraud the company. Further, it is contended that, the complainant had taken the parivar medi-claim policy and had paid premium after realizing all the terms and conditions of the policy. As the Insurance is with effect from 24-05-2010 which is valid till 23-05-2011 and also knowing the fact that, the said policy issued by the opposite Insurance Company having TPA (third party administrator as per clause 3.5) with the MD India Health Care Service, (TPA) Pvt. Ltd., Bangalore which is a TPA company with National Insurance Company and it is a third party administrator for settlement of claim on behalf of this opposite No-1 as such, the complainant should directly approach the said MD India Health Care Service, (TPA) pvt. Ltd., Bangalore, as per the terms and conditions of the policy. That the third party administrator is the proper authority to settle the claim and dispute in question or having power to give cheque directly to the complainant in case claim is genuine or having power to repudiate the claim as per the clause 6 of the terms and conditions but the complainant applied for reimbursement of the claim to the TPA. As per the policy terms and conditions No.1 company’s liability would arise if the treatment of decease or injury contracted/suffered is incepted during the policy period. The total expenses incurred for any one illness is limited to 50% of over all some insured per family. Company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured mentioned in the schedule. But here in this case the complainant spouse already taken one claim under the same policy during the substances of the same valid period subsequently to the earlier claim for the same illness which the complainant wife was admitted in Sancheti Instituted for Orthopedic & Rehabilitation vide admission dt. 18-03-2011 and discharged on 23-03-2011 and we have paid the claim of Rs. 52,844/- by way of cheque and the said cheque is accepted and had issued the discharge voucher duly signed. As per the policy condition the patient can claim for one illness to the extent of 50% of the sum assured. Here sum assured is 2,50,000/- and its 50% will comes to Rs. 1,25,000/-. The complainant wife already claimed for her subsequent same illness co-relating to above claim, occurred on 18-03-2011 for Rs. 52,844/- which has been paid to the complainant wife and settled the matter by the TPA sent the cheque by TPA directly to the complainant spouse. Now, as per the condition we have to deduct the amount of Rs. 52,844/- from Rs. 1,25,000/- the balance amount of Rs. 72,156/- is entitled if the case is genuine, as per the conditions of the policy this amount is to be paid if the TPA , MD India Health Care Service, (TPA) pvt. Ltd., Bangalore gives his opinion that, the complainant wife is entitled for the same. Here in this case our TPA has not given any opinion to this Respondent and the TPA is the proper person to answer the claim as such, question of non settling the claim and deficiency in service on the part of this opposite does not arise at all.
It further submitted that, the complainant in his complaint initially, intentionally not made him as party to the proceeding and in the absence of his reply or repudiation of claim the complaint of the complainant is premature one, as such, very complaint itself is liable to be dismissed. There is no any deficiency in service on the part of this opposite in settlement of the claim of the complainant as TPA i.e, MD India Health Care Service, (TPA) pvt. Ltd., Bangalore is the competent and in absence of that, TPA complainant cannot claim anything from the present opposite, hence, sought for dismissal of the complaint as there was no deficiency in service on the part of this opposite.
4. In-view of the pleadings of the parties. Now the points that arise for our consideration and determination are that:
1) Whether the complainant has proves that, there is deficiency in service on the part of the opposite.?
2) Whether the complainant has entitled to get the compensation as prayed in the complainant.?
3) What order?
5. Our findings on the above points are as under:-
(1) In affirmative.
(2) In affirmative.
(3) In-view of the findings on Point Nos. 1 & 2, we proceed
to pass the final order for the following :
REASONS
POINT NO.1:-
6. To prove the case of complainant, his affidavit-evidence was filed, who is noted as PW-1. The documents Ex.P-1 to Ex.P-1(4) Ex.P-2 to Ex.P-2(52) Ex.P-1(3) to Ex.P-3, Ex.P-4, Ex.P-4(1) are marked. On the other hand, affidavit-evidence of the opposite No-1 Insurance Company was filed, he was noted as RW-1, Opposite No-2 remained absent placed Ex-Parte. Hence, no evidence on his part.
7. On perusal of the documents and pleadings of the parties, and submissions made by the learned advocate for complainant and opposites, we have noted the following points are to be discussed for to get the answer for Point No-1 & 2.
1. Whether the complainant has put her claim in the policy within time or not as contended by the opposite.
2. Who is the competent person to decide the claim under the policy in question.
3. Whether the complainant is entitled to claim any amount if, so then what percent.
For the first point is concerned, we have gone through the documents filed by the complainant i.e, Ex.P-1(4), hospitalization Benefit Policy bearing No. 604002/48/8500000050 issued by the opposite which is continued from 24-05-2010 to mid night of 23-05-2011. In the said policy the complainant and his wife are insured for an amount of Rs. 2,50,000/-. According to this policy condition the claim is to be made within the 30 days from the date of discharge from the hospital and regarding admission in the hospital matter is to be informed to the TPA within 24 hours as contended by the opposite. Now, the question before us is that, whether the complainant has fulfilled these two importance points or not. Now, we have perused the medical reports of Poona Hospital & Research Center, Pune. More particularly on perusal of the discharge summary card produced under Ex.P-2(17) this document discloses that, the wife of the complainant has admitted on 10-07-2010 in the above noted hospital and discharged on 11-07-2010 and she has been treated by two doctors by name Dr. Ashok Desai, and Dr. K.P. Runwal for her leg (left knee and lower limbs). Further, we have perused another document discharge summary filed under Ex.P-2(37) which discloses that, again she has been admitted on 11-07-2010 and discharged on 17-07-2010 further we have also perused IPD Bill filed under Ex.P-2(23) which discloses that, she has been admitted on 14-10-2010 and discharged on 20-10-2010 it means from these documents it is very clearly that, the wife of the complainant was admitted in the above said hospital on 10-07-2010, 11-07-2010 and 14-10-2010 and on 18-03-2011as per Ex.R-2 as contended by the complainant in his complaint.
Further on perusal of Ex.P-4(1) i.e, letter dt. 02-08-2011 written by the complainant to the Senior Branch Manager, opposite Insurance Company, clearly speaks that, the claim papers regarding medical treatment of the complainant wife is concerned under the policy bearing no. 604002/48/8500000050 have been submitted on 06-12-2010 it means the claim forms have been submitted after the lapse of more than one month as contended by the opposite. Further, we have tried to find out whether the complainant has intimated to the opposite No-2 regarding admission and discharge from the hospital. Perused the documents filed by the complainant, but in the said documents, no documents were made available whether they have been intimated regarding their admission in the hospital or discharge from the hospital to the opposite No-2. On perusal of the policy condition the complainant has to inform the TPA i.e, third party administrator opposite No-2 within 24 hours from the date of admission and claims should be submitted within one month from the date of discharge. But the complainant has not fulfilled the conditions as contended by the opposite, from this it is very clear that, the complainant has failed to submit her claim form within the stipulated period. But Ex.R-3 is clearly speaks that, even though there is a delay the opposite have settled the claim, after receipt of the proper explanation or reasons for the delay. Under such circumstances, though there is a delay the opposites have rights to settle the guanine claim of the complainant. No doubt there is a delay but on that ground only the claim cannot be rejected.
For the second point is concerned, we have gone through the hospitalization benefit policy of the complainant and its terms and conditions under Ex.R-1 = Ex.P-1(4) field by the opposite No-1 and complainant respectively, wherein the details of the TPA are as given, and the terms and conditions of the said policy in related to TPA are also given under the para 3.5 wherein it is clearly mentioned that, the TPA is licenced by the insurance regulatory and development authority and is engaged for a fee or remuneration by whatever name called as may be specified in the agreement with the company for the provisions of health services. Further it is also very much clear as stated supra that, the claim form is to be submitted to the TPA within one month and they are the final authority to settle the claim of the complainant. But further we have perused Ex.R-2 wherein the TPA i.e, M.D. India Health Care services Pvt. Ltd., has written a letter to the complainant for to submit some of the documents/explanation regarding delay in intimation and as well as submission of claim and after that they have settled the claim of the complainant to the tune of Rs. 52,844/- in respect of medical bills for the period of admission in the hospital from 18-03-2011 to 23-03-2011 through cheque and same has been accepted it means as per Point No-2 the opposite NO-2 is the final authority to discharge the claim of the complainant. Hence, the complainant has put his claim within time to the opposite No-2 in order to claim her medi claim.
The third point is concerned, we have perused Ex.R-2 wherein the opposite No-2 has settled the claim of the complainant regarding the continuous treatment of the wife of the complainant for the same illness from 18-03-2011 to 23-03-2011 to the tune of Rs. 52,844/-. Further the said document discloses that, they have received the claim/documents on 04-06-2011 whereas that should have been submitted by 23-04-2011, no doubt there is a delay of three months but same has been accepted by the opposite No-1 & 2 and settled the amount to the tune of Rs. 52,844/- but it is worthwhile to note here that, though the complainant has submitted his claim for earlier treatments that has been rejected on the ground that, the claim has not been submitted within the prescribed period as per the terms and conditions. Here we do not find the reason whey they have rejected earlier three claims in respect of date of admission on 10-07-2010, 11-07-2010 and 14-10-2010 though it has been intimated on 06-12-2010 in respect of all the three claims is concerned, and why they have settled it means the opposite No-2 is not following his own rules regarding acceptance of the claim and discharge of the same. Under such circumstances, the rejection of the claim of the complainant in respect of first three admission and discharge date holds no good. No doubt, the entire claim may be such claim may be more than 50% but they are suppose to settle the claim according to permissible percentage in respect of the total claim entitled by the complainant. Therefore we have come to the conclusion that, as per the policy terms and conditions the complainant is entitled to claim totally 50% of the sum assured it means Rs. 1,25,000/- is the entitled claim. Hence, the opposites are liable to pay the same. Further, the complainant she has already taken 52,844/- from her fourth time medical bills i.e, for the treatment period from 18-03-2011 to 23-03-2011, but, now she is entitled to only to the tune of Rs. 72,156/- (1,25,000- 52,844 = 72,156). But not Rs. 1,34,114/- as contended by the complainant.
The policy in question of the complainant and entitlement of medi claim under the such policy by both husband and wife i.e, complainant and his wife, the policy in question is running while continues treatment for same illness and spending for huge amount for the same is not disputed by the insurance company. However, they are denying the time factor in respect of submitting the claim and intimation regarding the hospitalization. No doubt such delay has been made available before this Forum by the opposite. But mere rejecting the claim on the same ground (for earlier three claims) and accepting the fourth time treatment bills though there is a delay clearly goes to show that, some irregularity in the following procedures and terms and conditions so called mentioned under the terms and conditions of the policy by the opposite. Hence, they well and wish should in settling the claim should not be harmful to the policy holder who has put forth his claim under genuine condition. Hence, we have rejected the defence of the opposite and accepted the claim of the complainant as it is proper one. Hence, we find there is a deficiency on the part of the opposite and answered point No-1 in affirmative.
POINT NO.2:-
8. The complainant in his complaint has claimed in all Rs.1,13,114/- along with interest and other benefits and also Rs. 1,00,000/- towards damages it means he claim in all Rs. 2,13,114/- but as per the policy terms and conditions, he is entitled only 50% of the sum assured it means the sum assured is Rs. 2,50,000/- and half half it is Rs. 1,25,000/- out of which the complainant is already received Rs. 52,844/- and balance amount is only Rs. 72,156/- hence, the claim of the complainant to the tune of Rs. 1,13,114/- is not accepted. Further, the claim of Rs. 1,00,000/- towards damages, cost and deficiency in service is concerned, it is excessive and exorbitant one, so we have come to the conclusion that, it is fit to be award Rs. 3,000/- towards deficiency in service and Rs. 3,000/- towards cost of the litigation. The complainant is also entitled to get 9% p.a. interest on the total sum of Rs. 78,156/- from the date of this complaint till realization of the full amount., accordingly we answered Point No-2.
POINT NO.3:-
9. In view of the findings on Point Nos. 1 & 2 , we proceed to pass the following order.
ORDER
The complaint filed by the complainant is partly allowed with cost.
Complainant is entitled to recover total amount of Rs. 78,156/- from opposite Nos. 1 & 2 jointly and severally.
Complainant is also entitled to recover interest at the rate of 9% p.a. on Rs. 78,156/- from the date of this complaint till realization of the full amount.
Opposite is hereby granted one month time to make the said payment to the complainant from the date of this judgment.
Intimate the parties accordingly.
(Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 27-08-12)
Smt.Pratibha Rani Hiremath, Sri. Gururaj Sri. Pampapathi,
Member. Member. President,
District Consumer Forum Raichur. District Consumer Forum Raichur. District Consumer Forum Raichur.
