BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 12th May 2017
PRESENT
SRI VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SMT.LAVANYA M. RAI : HON’BLE MEMBER
ORDERS IN
C.C.No.157/2015
(Admitted on 27.4.2015)
Mr. Sudhakaran K.
S/o M.C. Krishnan Nair,
Aged about 54 years,
R/at. CAMPCO quarters,
Post Padil, Mangalore 575007.
……… Complainant
(Advocate for Complainant by Sri. KBA)
VERSUS
The Branch Manager,
United India Insurance Co.Ltd,
Krishna Prasad Building,
K.S.Rao Road,
Mangalore 575001
……. Opposite Party
(Advocate for opposite party by Sri. AKK)
ORDER DELIVERED BY HON’BLE MEMBER
SMT. LAVANYA M. RAI
- This complaint is filed under section 12 of the Consumer Protection Act alleging deficiency in service against the opposite party claiming certain reliefs.
The brief facts of the case are as under:
The complainant is the employee of CAMPCO ltd. The CAMPCO ltd, enrolled all its employees under the Opposite Partys cashless mediclaim benefit scheme called as Synd Arogya Scheme. On 17.7.2014 the complainant has got fever and chest pain and admitted in KMC hospital Mangalore as inpatient. After the treatment he was discharged on 17.7.2014 by clearing the bill amount of Rs.13,107/ because of Opposite Party has not release the claim amount. The complainant after discharge from the hospital, submitted the medical bills, with the claim form, to Opposite Party M/s . TTK Health care service pvt, ltd. The Opposite Party denied the claim of the complainant on the ground Hospitalization is not justified. On 21.2.2015 the complainant got issued a lawyer’s notice to the Opposite Party and demanded the bill amount but Opposite Party issued false reply and denied the claim. Hence the above complaint filed by the complainant before this forum under section 12 of the C.P.Act 1986(here in after referred to as the Act) seeking direction to the Opposite Party for payment of Rs.13,107/, and Rs.10,000/ as damages for mental tension and agony and such other reliefs.
II. Version Notice served to the opposite parties by RPAD, the Opposite Party filed version stating that the Opposite Party admits the issue of Synd Arogya Group Mediclaim Insurance policy bearing No. 070801/4/13/14/000001711. On the account of M/S Campco ltd which is valid from 26.9.2013 to 25.9.2014. The Opposite Party states that policy referred above is group mediclaim policy, if any, is being processed by the TPA of this Opposite Party namely VIDAL HEALTH TPA Private ltd, and said TPA of this Opposite Party necessary party to the proceedings. Hence the above compliant is bad for non-joinder of necessary parties. Further, complainant was admitted with a history of fever and chest pain for which he was administered with oral medication and investigations conducted are OPD investigations which do not warrant hospitalization and in fact as per the medical reports of the complainant discloses that he was treated conservatively and ESCO test done was normal and out of the inpatient bills, the medicine bills are amounting to Rs.761.70 paisa only. From the medical reports, discharge summary it is evident that complainant’s admission to the hospital was mainly for investigation and evaluation purpose which could have been done on outpatient basis and expenses incurred on such treatment is not allowed under exclusion clause of the policy referred above therefore the claim of the complainant was repudiated by the Opposite Party, hence prays for dismissal.
III. In support of the above complaint, the complainant Mr. Sudhakaran K, filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked at Ex.C1 to C8. On behalf of the opposite party Mr. Pundalik M Nayak, (RW1) Divisional Manager, United India Insurance co. Ltd, of opposite party filed affidavit evidence and answered the interrogatories served and produced documents got marked at Ex.R1.
IV. In view of the above said facts, the points for arise for our consideration in the case are:
- Whether the Complainant proved that the Opposite Party committed deficiency in service?
- If so, whether the Complainant is entitled for any of the reliefs claimed?
- What order?
We have considered the arguments submitted by the complainant and Opposite Party and also considered the materials, placed before the Fora and answered the points are as follows:
Point No. (i) : Affirmative
Point No. (ii) : Affirmative
Point No. (iii): As per the final order.
REASONS
V. POINTS No. (i) and (ii): It is the case of the complainant that after given approval for admission to the hospital, the Opposite Party refused to honour the cashless benefit by the ground that Hospitalization is not justified. The complainant is obtained Ex.C1 from the Opposite Party is not disputed. Ex.C2, 3 and 4 reveals that the complainant admitted to the hospital for treatment. The Ex.C4 inpatient final bill of the KMC Hospital shows that the complainant admitted on 17.7.2014 and discharged on 19.7.2014 and also the hospital charges of Rs. 13,107/ of the complainant. The contention of the Opposite Party that, the complainant was admitted for fever and chest pain for which he was administered with oral medication and investigations OPD investigation do not warrant hospitalization. From the medical reports, discharge summary shows that investigation and evaluation purpose which could have been done on out patient basis and expenses incurred on such treatment is not allowed under Exclusion clause of the policy hence repudiated. Now the points for consideration is that the Ex.C4 clearly shows that the inpatient bill of Rs.13,107/-. The Opposite Party repudiated the claim that treatment is not allowed under the Exclusion clause of the policy but herein not produced the terms and conditions of the policy. Once the medical reports revels the treatment of the patient and the medical bills are given from the hospital authorities then how can a TPA of the insurance company calculated the medical bills and the medical report shows the evidence then repudiating the claim by one or other reason is bad in nature. The another contention of the Opposite Party is that the TPA of the Opposite Party is necessary party to the proceeding hence complaint is bad for non joinder of necessary parties, but herein the complainant obtained policy from the Opposite Party therefore the contract between Opposite Party and TPA is not with in the knowledge of the complainant. As per the instruction of the Opposite Party complainant sent the claim to the TPA hence the contention of non joinder of the TPA does not arise. If the Opposite Party have any doubts about the bills claimed by the complainant then Opposite Party would have been examine the doctor who treated to the complainant. Absence of oral as well as documentary evidence the Opposite Party repudiated the claim is not justified and which amounts to deficiency in service. Therefore the complainant entitled for Rs.13,107/ as medical expenses along with 9% interest from the date of discharge till the date of payment, and Rs.10,000/ as compensation and further pay Rs.10,000/ as litigation expenses is meets ends of justice, hence we answer point No.1 and 2 in the Affirmative.
In the result, accordingly we pass the following Order.
ORDER
The complaint is allowed with cost. Opposite Party shall pay Rs.13,107/ (Rupees thirteen thousand one hundred seven only) as medical expenses along with 9% interest from the date of discharge till the date of payment, and Rs.10,000/ (Rupees Ten thousand only) as compensation, further pay Rs.10,000/ (Rupees Ten thousand only) as litigation expenses. Payment shall be made within 30 days from the date of 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 7 directly dictated by Member to the Stenographer typed by him, revised and pronounced in the open court on this the 12th May 2017)
MEMBER PRESIDENT
(LAVANYA M RAI) (VISHWESHWARA BHAT D)
D.K. District Consumer Forum D.K. District Consumer Forum
Mangalore Mangalore
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 Mr. Sudhakaran K
Documents marked on behalf of the Complainant:
Ex.C1: The Health Card.
Ex.C2: 18.7.2014: Copy of the cardiac scan report and other documents.
Ex.C3: 18.7.2014: The copy of the discharge summary issued by Mr.M.N.Bhat.
Ex.C4: 19.7.2014: Copy of the bill issued by KMC.
Ex.C5: 4.8.2014: The copy of the claim form.
Ex.C6: 9.2.2015: The copy of the letter issued by the Opposite Party No claim.
Ex.C7: 21.2.2015: The copy of the lawyers notice.
Ex.C8: 17.3.2015: Copy of the reply of the Opposite Party.
Witnesses examined on behalf of the Opposite Party:
RW1: Mr. Pundalik M Nayak, Divisional Manager, United India Insurance co. Ltd
Documents marked on behalf of the Opposite Party:
Ex.R1: Synd Arogya Group Mediclaim Insurance policy bearing No.070801/48/13/14/00001711.
Dated: 12.05.2017 MEMBER
