Complaint filed on: 30.12.2016

                                                                                                                             Complaint Disposed on:15.07.2017

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AT CHICKMAGALUR.

COMPLAINT NO.120/2016

DATED THIS THE 15^th DAY OF JULY 2017

:PRESENT:

HON’BLE SRI RAVISHANKAR, B.A.L, LL.B., - PRESIDENT

HON’BLE SMT B.U.GEETHA, M. COM., LL.B., -MEMBER

HON’BLE SMT H. MANJULA, B.A.L., LL.B., - MEMBER

COMPLAINANT:

Sri.Ravi S.Hegde,

R/o No.124,Punarvasu,

1^st Cross, Kuvempu Nagara,

Chikmagalur Town.

(By Sri/Smt. V.R.Poornesha, Advocate)

V/s

OPPONENT:

1. The Chief Manager,

    United India Insurance Co., Ltd.,

    Divisional Office,:010500,

    Catholic Centre, 64, Armenenian

    Street, Chennai-600001.

2. The Manager,

    Vidal helath TPA Pvt. Ltd.,

    ANMOL PALANI, No.88,

    GN.CHETTI ROAD, L2,

    T.Nagar, Chennai.

3. The Manager,

    Indian Bank,

    M.G Road,

    Chikmagalur.

(OP Nos.1 to 3 -Exparte)

By Hon’ble President Sri. Ravishankar,

:O R D E R:

The complainant filed this complaint U/s 12 of the Consumer Protection Act 1986 against OP Nos.1 to 3 alleging deficiency in service in not settling the claim towards medical expenses. Hence, prays for direction against Op Nos.1 to 3 to pay the claim amount of Rs.7,369/- along with compensation of Rs.10,000/- for deficiency in service.

2.     The brief facts of the complaint is that:

        The complainant had obtained AROGYA RAKSHA health insurance from Op No.1 through Op No.2 and 3 and paid Rs.4,604/- towards premium, for which Op No.1 issued a policy which is valid from 04.05.2016 to 30.04.2017. The complainant had paid the premium since 6 years without any fail and renewed periodically. Such being the case, complainant hospitalized at Anuradha Hospital, Chikmagalur on 30.06.2016 for abdoman pain at disc prolapse, subsequently, after treatment he discharged from hospital on 02.07.2016 during the hospitalization complainant had spent nearly Rs.7,369/- towards treatment. The complainant intimated Op No.2 and also sent a claim form along with medical bills and required documents in order to claim the reimbursement of the medical expenses. After receipt of the said claim form the TPA informed the complainant that it was linked with Vidal Health and running its office in Bangalore and repudiated the claim without any valid reasons. Thereafter, the complainant intimated the said fact to the present TPA to settle the claim and also submitted the required documents along with a letter for reimbursement on 11.08.2016, the Op had received complainant requisition as per letter vide No.CHE-0816-CC-0003734 and intimated that the claim has been kept for internal processing. But so far Op No.1 had not settled the claim of the complainant. Inspite of repeated requests also Op No.1 being insurer failed to settle the claim of the complainant.

        Finally, complainant issued a legal noticed dated 30.11.2016 and called upon the Ops to settle the claim, but even inspite of receipt of the legal notice Op Nos.1 to 3 failed to settle the claim. Hence, Op Nos.1 to 3 rendered deficiency in service and complainant filed this complaint and prays for direction against Op Nos.1 to 3 to settle the claim along with compensation for deficiency in service as prayed above.   

3. After service of notice Op Nos.1 to 3 not appeared before this Forum to defend the allegations made by complainant. Hence, Op Nos.1 to 3 placed exparte.

4. Complainant filed affidavit and marked documents as Ex.P.1 to P.5.

5.     Heard the arguments.

6.     In the proceedings, the following points do arise for our consideration and decision:

1. Whether there is deficiency in service on the part of OP Nos.1 to 3?
2. Whether complainant entitled for any relief & what Order?

7.     Our findings on the above points are as follows:-

1. Point No.1: Affirmative.
2. Point No.2: As per Order below. 

: R E A S O N S :

POINT NOs. 1 & 2:

8. On going through the pleading, affidavit and documents produced by complainant there is no dispute that the complainant had obtained AROGYA RAKSHA mediclaim insurance policy bearing No.0105002016484100000571983 from Op No.1. The said insurance is renewed periodically and now is valid from 04.05.2016 to 30.04.2017. The complainant in his affidavit has sworn that he was hospitalized for a pain in abdomen from 30.06.2016 and discharged on 02.07.2016. During hospitalization he spent Rs.7,369/- towards treatment. After treatment being a beneficiary of the policy he claimed for reimbursement of the said medical expenses and submitted all required documents. The complainant also sworn that he had furnished all original medical bills and discharge summary along with claim form. Hence he produced a copy of the Discharge Summary marked as Ex.P.1, Copy of the Medical Bills marked as Ex.P.2, Copy of the Claim Form marked as Ex.P.3, Copy of the policy/Certificate for AROGYA RAKSHA marked as Ex.P.4 and Office copy of the legal notice marked as Ex.P.5 in support of his allegations.

        This Forum has issued notices to Op Nos.1 to 3 to appear before this Forum to answer the allegations made by complainant, but inspite of receipt of the cause notice Op Nos.1 to 3 not appeared before this Forum to answer the allegation made by complainant and at the same time complainant established that he is a beneficiary under the policy issued by Op No.1. The Op No.1 being insurer even not cared to reply the legal notice issued by complainant. Hence, We are of the opinion that Op No.1 being insurer is liable to pay the medical expenses which was spent by complainant during hospitalization. Here Op No.2 and 3 are merely a bankers of the complainant, who introduced Op No.1 to issue the policy to the complainant. Hence, Op Nos.2 and 3 are not liable to pay any reimbursement to the complainant and we found there is no any deficiency in service on the part of Op Nos.2 and 3. Anyhow Op No.1 rendered a deficiency in service in not settling the claim of the complainant, even inspite of receipt of the claim form with required documents and even after receipt of legal notice. Therefore, Op No.1 is also liable to pay compensation of Rs.3,000/- for deficiency in service along with litigation expenses of Rs.1,000/- to the complainant. As such for the above said reasons, we answer the above point no.1 and 2 in the Affirmative and proceed to pass the following:-  

: O R D E R :

1. The complaint filed by the complainant is partly allowed.
2. OP No.1 is directed to settle the claim of the complainant towards medical expenses along with compensation of Rs. 3,000/- (Three Thousand Rupees only) for deficiency in service and litigation expenses Rs.1,000/- (One thousand Rupees only)  to the complainant within one month from the date of receipt/knowledge of the order, failing which the payable amount shall carry interest @ 9% P.A. till realization.
3. The Complaint against Op No.2 and 3 is hereby  dismissed.
4. Send free copies of this order to both the parties.

(Dictated to the Stenographer transcribed typed by her, transcript corrected by me and then pronounced in Open Court on this the 15^th day of July 2017).

  (B.U.GEETHA)         (H.MANJULA)      (RAVISHANKAR)

      Member                   Member                         President

ANNEXURES

Documents produced on behalf of the Complainant/S:

Ex.P.1              - Copy of the Discharge Summary.

Ex.P.2              - Copy of the Medical Bills.

Ex.P.3             - Copy of the Claim Form.

Ex.P.4              - Copy of the Policy.

Ex.P.5              - Office copy of the legal notice.

Documents produced on behalf of the OP/S:

NIL

Dated:15.07.2017                         President 

                                           District Consumer Forum,

                                                  Chikmagalur.            

RMA