BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE
Dated this the 14th December 2016
PRESENT
SRI. VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SRI. T.C. RAJASHEKAR : HON’BLE MEMBER
ORDER IN
C.C.No.434/2014
(Admitted on 18.11.2014)
Sandeep Kumar K,
Aged 42 years,
S/o Ramakrishna Pillai,
Residing at Sanjana,
1st Cross Road, Shivanagar,
Pandeshwar, Mangalore 01.
….. COMPLAINANT
(Advocate for the Complainant: Sri. BMD)
VERSUS
The Branch Manager,
National Insurance Company Ltd.,
2nd Floor, Inland Ornate,
Opposite Hotel Ocean Pearl,
Kodialbail, Mangalore 03.
......OPPOSITE PARTY
(Advocate for the Opposite Part: Sri. UNK)
ORDER DELIVERED BY HON’BLE PRESIDENT
SRI. VISHWESHWARA BHAT D:
I. 1. The above complaint filed under Section 12 of the Consumer Protection Act alleging deficiency in service against claiming certain reliefs.
The brief facts of the case are as under:
The case of the parties are that the complainant obtained Medi claim policy from holder of opposite party since 9 years with effective policy from 22.10.2013 to 21.102014 covering his risk and his wife and also his daughter to the extent of Rs.1,0000/. Due to ill health he was admitted as inpatient and treated from 31.08.2014 to 07.09.2014 at Mangala Hospital, Kadri Road, Mangalore which resulted in his expenditure of Rs.60,000/.
II. The claim of complainant was rejected by opposite party on the ground complainant was admitted for acute lower back pain and other consequences and the Physiotherapy. Hence seeks dismissal of the complaint.
2. In support of the above complainant Mr. Sandeep Kumar K filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents marked Ex.C1 to C9. On behalf of the opposite party Mr. Bhavanishankar (RW1) Assistant Manager also filed affidavit evidence and answered the interrogatories served on him.
III. In view of the above said facts, the points for consideration in the case are:
- Whether the Complainant is a consumer and the dispute between the parties?
- If so, whether the Complainant is entitled for any of the other reliefs claimed?
- What order?
We have considered the notes/oral arguments submitted by the learned counsels and also considered the materials that was placed before this Forum and answer the points are as follows:
Point No. (i): Affirmative
Point No. (ii): Affirmative
Point No.(iii): As per the final order.
REASONS
IV. POINTS No. (i): The complainant had purchased Medi Claim policy of opposite party since 9 years with current ploicy as mentioned in the complaint is undisputed. The claim of complainant for medical expenditure for treatment at Mangala hospital was repudiated is also not in dispute. As such there is a live dispute between complainant the consumer and the opponent the service provider. Hence we answer point No.1 in the affirmative
POINTS No.(ii): The ground on which the claim of complainant was rejected is the treatment of complainant as inpatient was for lower back pain only conservatively. Hence under the terms of the policy as per opposite party complainant is not entitled for reimbursement. Ex.C7 is the document pertaining to the hospital including discharge summary, it mentions the complainant was admitted with history of lower back pain since morning. This is endorsement of I P No.36062 progress sheet of duty Doctors. Discharge summary mentions history of sudden onset of low back ache since 1 day, following which pt is unable to move. No h/o trauma/fall. K/C/O HTN/DM on Rx.
2. Ex.C1 is the insurance policy mentions the clause and description in the list of the clause extended warranty as follows:
Clause No. Description:
This insurance shall be extended after 48 months of continuous coverage has elapsed since inception of the first policy to pay any expenses incurred relating to the disease(s)/sickness/injury mentioned in the row Pre existing Disease/Exclusion and for consequences attributable thereto or accelerated thereby or arising therefore, in respect on the respective insured person.
3. As we can find the opposite party has not produced the insurance policy with full terms and conditions to support the contention raised by opposite party that as complainant was treated conservatively and as such not entitled for coverage and as such repudiated cannot be justified. In the circumstance hence we are of the view it is a fit case to direct opposite party to pay the claim of complainant Rs.60,000/ with interest at the rate of 9% towards medical expenditure from the date of complaint and another sum of Rs. 20,000/ as compensation and cost of the notice Rs.500/ and the cost of the petition. Advocate Fee fixed at Rs.2,000/. Hence we answer point No.2 in the affirmative.
POINTS No. (iii): Wherefore the following order
ORDER
The Complaint is allowed. The opposite party is directed to pay complainant Rs.60,000/ (Rupees Sixty thousand only) with interest at the rate of 9% towards medical expenditure from the date of complaint and another sum of Rs. 20,000/ (Rupees Twenty thousand only) towards compensation and cost of the notice Rs.500/ (Rupees Five hundred only) and the cost of the petition. Advocate Fee fixed at Rs.2,000/ (Rupees Two thousand only). Payment shall pay within 30 days from the date of the receipt of copy of this order.
Copy of this order as per statutory requirements, be forwarded to the parties free of cost and file shall be consigned to record room.
(Page No.1 to 5 directly dictated by President to computer system to the Stenographer typed by her, revised and pronounced in the open court on this the 14th December 2016)
MEMBER PRESIDENT
(SRI. T.C. RAJASHEKAR) (SRI. VISHWESHWARA BHAT D)
D.K. District Consumer Forum D.K. District Consumer Forum
Additional Bench, Mangalore Additional Bench, Mangalore
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 Mr. Sandeep Kumar K
Documents marked on behalf of the Complainant:
Ex.C1: : Original of Medi claim Insurance Policy
Ex.C2: : Original of Discharge Summary
Ex.C3: : Original of Cash Bill
Ex.C4: 25.09.2014 : Original of Office copy of notice
Ex.C5: : Original of Acknowledgement
Ex.C6: : Original of Reply Notice
Ex.C7: : Case Sheet
Ex.C8: : x Rays 5 in Nos.
Ex.C9: : MRI Report
Witnesses examined on behalf of the Opposite Parties:
RW1 Mr. Bhavanishankar , Assistant Manager
Documents marked on behalf of the Opposite Parties:
Nil
Dated: 14.12.2016 PRESIDENT
