JUDGEMENT<br /> <br /> This is a complaint filed U/s. 12 of Consumer Protection Act by the complainant Ramachandra Prabhu.U. against Respondent No-1. Branch Manager United India Insurance Company Ltd., Raichur and Respondent No.2 Authorized Signatory, Med Save Health Care Limited (Claims Department) Bangalore. The brief facts of the complaint are as under: <br /> <br /> The complainant had obtained policy bearing NO. 24000/48/02/00576 dt. 28-07-03 from Respondent NO-1 for the period from 19-09-02 to 18-09-03 for a sum of Rs. 75,000/- and paid the premium amount of Rs. 1,515/-. The Respondent NO-1 is Insurer and Respondent NO-2 is Company which under took the insurance claims of Respondent No-1 being the arrangement between them. This complainant is no way concerned to this arrangements made between the Respondents. This policy covered the complainant’s sickness of any kind and the Insurer has to reimburse all expenses of treatment including hospitalization, medical bills, Doctors bills etc,.<br /> <br /> On 20-08-03 the complainant felt pain in groin. For that he consulted local Dr. V.J. Kataria at Raichur who referred him for scanning report. As per scanning report dt. 20-08-03 of Ashakiran Imagining Center, Raichur, “Bilateral Ranel Calculi” was found and he took treatment accordingly. Since there was no improvement the complainant again consulted Dr. B.Mahalinga who again sent him for scanning report. As per scan report dt. 24-08-03 of Ashakiran Imagining Center, Raichur the same report came i.e, “Bilateral Ranel Calculi”. Since there was no improvement and as it was kidney related ailment the complainant proceeding to Mangalore on the advise of his brother Dr. Vishnu Prabhu to take treatment in specialized Kidney Center. On 27-08-03 the complainant was admitted in Athena Hospital Mangalore. The doctors who treated him were Dr. M.C. Suvarna & Dr. A.V. Manjunath of Urology Research Center & Stone Clinic gave treatment. As these doctors do not have their own Nursing Home so he was admitted in Athena Hospital by these doctors. Stunt was put to patient/complainant to discharge Urine. He used to get fever and other complications so treatment continued upto 10-09-03. His medical bills of Athena Hospital, Discharge Summary, Treatment Sheet and other medical bills etc., shows that he took treatment in the said hospital from 27-08-03 to 10-09-03. Since the complainant’s brother Dr. Vishnu Prabhu is at Mangalore, so everyday the complainant used to return to Home of his brother without getting discharged from the Hospital. The Hospital charged Rs. 3,225/- for the period from 27-08-03, the date of admission till 10-09-03 the date of discharge and he has paid the same accordingly. He has also paid other charges and in total he has paid Rs. 45,051.80/-Ps. <br /> <br /> On 13-12-05 the complainant submitted Insurance Claim Form to Respondent No-1 along with other necessary forms for the total claim of Rs. 45,051.80/-Ps. He received a letter dt. 20-12-03 from Respondent NO-2 asking him for more details of investigation reports etc., Accordingly the complainant sent all original investigation reports with his covering letter dt. 28-01-04. Respondent NO-2 wrote a letter dt. 25-02-04 to Respondent No-1 and sent a copy to the complainant, wherein they had admitted the expenses of his treatment but they asked Respondent NO-1 to review his claim. He sent a reminder letter for early settlement of his claim. The Respondent NO-2 rejected his claim on false and flimsy grounds vide letter dt. 14-07-04.<br /> <br /> The total medical treatment bills submitted by him for claim is for Rs. 45,051.80/- Ps. and out of which Rs. 3,225/- is only hospital bills of Athena Hospital, Mangaloge and remaining are towards his treatment. The Respondent with malice intention stated that the hospital bills are fake. In-fact complainant was admitted in the hospital on 27-08-03 and was discharged from hospital on 10-09-03. In-case the hospital people by mistake stated that he was admitted in the hospital for only one day is not responsible for that it is for the Respondents to prove the same. So the repudiation of his claim by the Respondent amounts to deficiency of service. Hence for all these reasons the complainant has sought for direction to Respondent to pay assured amount of Rs. 45,051.80/- Ps. with interest and cost.<br /> <br /> 2. In response to service of notice, Respondent NO-1 appeared through counsel and filed written version. But Respondent No-2, in-response to service of notice, remained absent so he has been placed Ex-parte. In the written statement, the Respondent No-1 Insurance Company has contended that as per the existing treatment and the records & investigation of Respondent Company the complainant got treated as in-patient in the Hospital and was admitted on 27-08-03 at 13-11 hours and was discharged on 28-08-03 at 15.42 hours and he has paid a sum of Rs. 285/- only vide bill No. 0000008212 of the said Hospital. The said bill which is the authenticated is produced under list of documents by this Respondent. In view of the same, the other documents produced by the complainant are got up in collusion with the concerned persons as such the same are totally disputed by this Respondent. The complainant has neither sustained any disease as alleged nor was treated for that. Except the treatment of one day, the complainant has not taken any treatment with other authorities, doctors and hospital and the certificates, bills etc., produced are all got up and cannot be considered for any purpose. <br /> <br /> As per condition No.5.7 of the Insurance Policy, the company shall not be liable to make any payment under this policy in-respect of any claim if such claim be in any manner of fraudulent or supported by any fraudulent means or device where by the insured person or by any other person acting on his behalf. The said condition has been violated by the complainant and in-view of violation of the condition the complainant is not entitled to any reliefs. <br /> The complainant has not suffered any pain in groin and he has been treated for only one day as in-patient and discharged from the hospital as the said pain was neither grievous nor required such treatment and to be treated as in-patient. The documents produced by him are all fictious got up and obtained fraudulently. Hence the same are disputed. The complainant has not furnished the relevant particulars and the documents as directed by the Respondent. The complainant has no cause of action and there is no deficiency of service on the part of this Respondent. The compensation amount claimed at Rs. 45051.80/- Ps is totally on fabricated documents and the same is very high, excessive, exorbitant, imaginary and against the condition of the policy. Hence for all these reasons the Respondent No-1 has sought for dismissal of the complaint with cost.<br /> <br /> 3. During the course of enquiry the complainant Ramachandra Prabhu.U. filed his sworn affidavit as PW-1 by way of examination-in-chief and got marked (19) documents at Ex.P-1 to P-19. The contesting Respondent NO-1 in rebuttal has filed sworn affidavit of its Administrative Officer as RW-1 by way of examination-in-chief and got marked (3) documents at Ex.R-1 to R-3. It is pertaining to note here itself that during the course of enquiry the Respondent NO-1 has filed Interrogatories No. 1 to 4 to which the complainant replied the same. During the course of hearing on Interrogatories, with consent of both sides, the Xerox copy of disputed bill No. 0000008212 of Athena Hospital for Rs. 3,225/- produced by the complainant at Ex.P-8 (18) and Xerox copy of disputed bill of same number of same hospital for Rs. 285/- produced by the Respondent NO-1 at Ex.R-3 were sent to Athena Hospital Mangalore asking to the report the genuiness of the two bills since the two bills issued by the hospital bear the same number but for different amount. Athena Hospital Authority through their letter dt. 03-03-07 reported that on going through the computer they found the only bill No. 0000008212 for Rs. 285/- in the name of Ramachandra Prabhu and they have enclosed duplicate copy of bill obtained from the computer. This duplicate copy of bill shows bill No. 0000008212 in the name of Ramachandra Prabhu for Rs. 285/- showing description as Admission charges Rs. 75/-, Room Rent Rs. 130/-, Nursing charges Rs. 80/- totaling to Rs. 285/-. This duplicate copy of bill of Athena Hospital has been marked as Ex.R-3(A) and covering letter has been marked as Ex.R-3(A-1).<br /> <br /> 4. Heard the arguments of both sides and perused the records. The following points arise for our consideration and determination:<br /> 1. Whether the complainant proves deficiency in service by both the Respondents, as alleged.?<br /> <br /> 2. Whether the complainant is entitled for the reliefs sought <br /> for?<br /> <br /> 5. Our finding on the above points are as under:-<br /> 1. In the Negative. <br /> 2. As per final order for the following.<br /> <br /> REASONS<br /> <br /> POINT NO.1 :-<br /> <br /> 6. There is no dispute that the complainant had obtained Medi Claim Insurance Policy for the assured sum of Rs. 75,000/- from Respondent No-1 for a period from 19-09-02 to 18-09-03 and had paid necessary premium of Rs. 1,515/-. The Medi Claim Policy produced by the complainant is at Ex.P-1. The Respondents has also produced the copy of same at Ex.R-1 along with its condition (M.C. Policy) at Ex.R-2. It is the case of the complainant that on 20-08-03 he felt pain in groin and consulted Dr. V.J. Kataria at Raichur and after scanning report dt. 20-08-03 of Ashakiran Imaging Center Raichur, “Bilateral Ranel Calculi” was found and accordingly he took treatment. Since there was no improvement he consulted Dr. B.Mahalinga of Raichur who sent him for scan report. The same report came i.e, “Bilateral Ranel Calculi”, as per scan report dt. 24-08-03 of Ashakiran Imagining Center Raichur. As there was no improvement and it was kidney related ailment so he proceeded to Mangalore on the advise of his brother Dr. Vishnu Prabhu to take treatment in specialized Kidney Center. On 27-08-03 he admitted in Athena Hospital Mangalore. The doctors who treated him in Mangalore were Dr. M.C. Suvarna & Dr. A.V. Mallikarjuna of Urology Research Center and Stone Clinic. It is also his case that since these doctors do not have their own Nursing Home so he was admitted in Athena Hospital by those doctors. Stunt was put to him to discharge Urine and he used to get fever and other complications and treatment continued upto 10-09-03. It is also his case that since his brother Dr. Vishnu Prabhu was at Mangalore so everyday he used to return to the house of his brother without getting discharged from the Hospital. The said hospital charged Rs. 3,225/- for his treatment from 27-08-03 to 10-09-03 as date of admission and date of discharge and he has paid the said amount accordingly. He has also paid other charges etc., in total Rs. 45,051.80.<br /> <br /> 7. The contesting Respondent NO-1 Insurance Company has disputed the claim of the complainant on the ground that the complainant got treated as in-patient in the Athena Hospital and was admitted on 27-08-03 at 13.11 hours and discharged on 28-08-03 at 15.42 hours and has paid a sum of Rs. 285/- only vide Bill No. 0000008212 of the said hospital which is authenticated one. So the other documents produced by the complainant are got up in collusion with the concerned persons as such they are disputed by the Respondents. Except the treatment of one day the complainant has not taken any treatment with other authorities, doctors and hospital and certificates, bills etc., produced are all got up and cannot be considered for any purposes.<br /> <br /> 8. The complainant has produced Repudiation letter of Respondent NO-2 Med Save Health Care Ltd., Bangalore dt. 14-07-04 at Ex.P-16. This letter which is short one and material reads as under:<br /> “Dear Sir,<br /> This is to inform you that your claim is inadmissible for the following reason/s.<br /> You have stated in your claim form that you had been hospitalized from 27-08-2003 to 10-09-2003 in Athena Hospital. On enquiry and scrutiny of the original records of the hospital we found that you were hospitalized just for a day i.e, Date of admission__ 27-08-2003 and Date of discharge__28-08-2003. Moreover the bill of Urology Research Centre & Stone Clinic submitted is not all proper. It is clearly evident from the documents submitted by you and the facts collected by us on verification and enquiry, that you have given fake information. This manipulation of vital information amounts to fraud and violation of policy conditions at your end. Hence your claim stands repudiated.<br /> The repudiation of this claim is without prejudice. However, you have a right to make a representation to the Insurance Company within 15 days of receipt of this letter.<br /> Yours truly,<br /> For Med Save Health Care Limited,<br /> Sd/-<br /> Authorized Signatory<br /> Claims Department<br /> Bangalore.<br /> Cc: United India Insurance Co Ltd., Gandhi Chowk, Raichur”.<br /> <br /> 9. The complainant has produced the bill of Athena Hospital bearing NO. 0000008212 for Rs. 3,225/-vide Ex.P-8(18) whereas the Respondent has produced bill bearing the same number viz., bill No. 0000008212 for Rs. 285/- at Ex.R-3. As stated above during enquiry of complaint the L.C. for the Respondent NO-1 has filed Interrogatories asking the complainant to answer four questions and the complainant has replied to the said Interrogatories by answering to the four questions. For sake of clear understanding the Interrogatories and Reply are re-produced as under:<br /> Interogatories Reply <br /> 1) Whether there are any Hospital bill medical bills of No.<br /> same numbers and same date of different amount ?<br /> 2) That, you have prepared all false medical bills hospital No. All bills are genuine <br /> bill and other medical documents which are filed with an <br /> intention to claim compensation<br /> 3)You have falsely stated that you are suffering from No, Actually complaint is <br /> “Bilateral Renal Calculi” suffering” Bilateral Renal <br /> Calculi”<br /> <br /> 4) Hyderabad Kidney center is near to Raichur any person There is no rule as all Raichur<br /> suffering from kidney ailment use to go to Hyderabad patients should go to Hyderabad.<br /> but you went to Mangalore to prepare false medical Since Mangalore is negative district<br /> bills and other medical documents. of complaint, he went there.<br /> <br /> 10. As stated supra in-order to know the genuiness of the two bills bearing same Bill No. with different quantum of amount, filed by the parties at Ex.P-8 (18) and at Ex.R-3, so with the consent of both the Counsel, the two bills were sent to Athena Hospital Mangnalore. The Athena Hospital Authorities have reported the genuiness of the bill for Rs. 285/- (produced by Respondent at Ex.R-3) and sent a computerized bill of same No. i.e, bill No. 0000008212 for Rs. 285/- which is marked as Ex.R-3(A) and covering letter of the Athena hospital dt. 03-03-07 at Ex.R-3(A-1). Admittedly the Respondent NO-1 has disputed the bill at Ex.P-8(18) produced by the complainant for Rs. 3,225/- bearing No. 0000008212 as against the bill for Rs. 285/- bearing same bill No. 0000008212 issued by the Athena Hospital and the Respondents have repudiated the claim of the complainant vide repudiation letter dt. 14-07-04 at Ex.P-16. <br /> <br /> 11. The complainant in his complaint has specifically stated that since the Dr. M.C. Suvarna & Dr. A.V. Mallikarjuna of Urology Research Center Stone Clinic who treated him at Mangalore do not have their own Nursing Home, so they got admitted him (complainant) in Athena Hospital on 27-08-03 and his treatment continued upto 10-09-03 as he used to get fever and other complications. The complainant has also stated that since his brother Dr. Vishnu Prabhu is at Mangalore so everyday he used to return to the house of his brother without getting discharged from the hospital. If this is so then how the Athena Hospital Authorities have issued the bill at Ex.R-3 = Ex.R-3(A) showing the date of admission as 27-08-03 at 13.11 hours and discharged date as 28-08-03 at 15.42 hours and showing the bill amount at Rs. 285/-. When the Athena Hospital Authorities submitted report as called for by this Forum stating that only bill issued by their hospital is bill bearing No. 0000008212 for Rs. 285/-, then in the natural course of events the complainant would have summoned the Athena Hospital Authorities or produced affidavit-evidence of Hospital Authorities regarding the bill for Rs. 3,225/- at Ex.P-8(18) bearing the same bill No. 0000008212 said to have issued by them, especially when the Respondents have repudiated the claim of the complainant on the ground that the bills submitted by the complainant (after enquiry and verification) found that they are fake and amounts to fraud and violation of terms and conditions. No explanation is coming forth on behalf of the complainant for non-examination of Athena Hospital Authorities regarding issuance of bill for Rs. 3,225/- at Ex.P-8(18). Further, when according to the complainant he used to go to the house of his brother without getting himself discharged from the hospital, then why the bill at Ex.R-3 = Ex.R-3(A) shows one day period of his admission in the hospital by specifically showing the date of discharge as 28-08-03 at 15-42 hours instead of 10-09-03 according to him. Of course the complainant has produced Xerox copy of Discharge Summary Sheet at Ex.P.19 showing the date of admission as 27-08-03 and date of discharge as 10-09-03. But why the complainant kept mum without taking any recourse to move the Hospital Authorities to explain the controversy between Discharge Summary at Ex.P-19 and the Bill for Rs. 285/- at Ex.R-3(A) showing in-patient of the complainant for only one day. Added to this the complainant even has not taken pains to adduce the evidence of his so called Attending doctors namely: Dr. M.C. Suvarna & Dr. A.V. Mallikarjuna Urology Research Center Stone Clinic to show that they got admitted the patient-complainant in Athena Hospital on 27-08-03 as they do not have their own Nursing Home and they attended the complainant in the Athena Hospital and treatment continued upto 10-09-03. The complainant even has not adduced evidence of Athena Hospital Authorities to clear the suspicious-cloud regarding his ailment and treatment and regarding disputed bill for Rs. 3,225/- at Ex.P-8(18) in support of his case. No explanation is coming forth for non-examination of his Attending doctors and the Hospital Authorities. In the absence of the same we have no option than to accept the contention of the Respondents that they have rightly disputed the entire claim of the complainant as per policy condition NO. 5.7 at Ex.R-2 which reads as under:<br /> “The company shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the Insured Person or by any other person acting on his behalf”<br /> <br /> Under these circumstances we do not find any merit in the contention of the complainant that the Respondents have falsely repudiated his claim and thereby they are deficient in service. So Point NO-1 is answered in the Negative.<br /> POINT NO.2:- <br /> 12. In-view of our finding on Point No-1 the complainant is not entitled for the reliefs sought for. In the result we pass the following order:<br /> <br /> ORDER<br /> <br /> The complaint of the complainant being devoid of merits is hereby dismissed. No order as to cost.<br /> <br /> Office to furnish a copy of this order to both the parties forth with free of cost.<br /> <br /> (Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 23-08-07)<br /> <br /> Sd/-<br /> Sri. N.H. Savalagi<br /> President<br /> Dist.Consumer Forum-Raichur.<br /> <br /> Sd/-<br /> Sri. Vishwanath Yekkelli<br /> Member.<br /> Dist.Consumer Forum-Raichur.