BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE
Dated this the 12th May 2017
PRESENT
SRI VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SRI T.C. RAJASHEKAR : HON’BLE MEMBER
ORDERS IN
C.C.No.385/2014
(Admitted on 26.9.2014)
Harischandra D. Suvarna,
S/o Late Doomappa Puthran,
Aged about 74 years,
Residing at Harideep, Chitrapura, Kulai,
Mangalore 575019.
….. COMPLAINANT
(Advocate for the Complainant: Sri DRKS)
VERSUS
The Divisional Manager,
National Insurance co.ltd, D.O.No.2,
Rasik Chambers, Opp. Central Market,
Mangalore 575001
…..........OPPOSITE PARTY
(Advocate for the Opposite Party: Smt. HM)
ORDER DELIVERED BY HON’BLE MEMBER
SRI T.C. RAJASHEKAR:
I. 1. The above complaint filed under Section 12 of the Consumer Protection Act 1986 alleging deficiency in service against the Opposite Party claiming, to pay reimburse the medical expenses Rs.95,655/, to pay interest at 18% p.a. from 24.2.2014 till the date of settlement, to pay compensation of Rs.25,000/, cost of the proceedings Rs.10,000/ cost of the lawyers notice Rs. 1,000/ and such other reliefs.
2. In support of the above complaint the complainant Harischandra D. Suvarna, filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked at Ex.C1 to C8 as detailed in the annexure here below. On behalf of the opposite parties Mr. Bhavanishankar, (RW1) Assistant Manager, also filed affidavit evidence answered the interrogatories served on him.
The brief facts of the case are as under:
On perusal of the complaint and the version we find the dispute is with regard to the mediclaim insurance not paid by the opposite party. The complainant case as per record is he had purchased a mediclaim insurance policy for his family from the opposite party. He had also another insurance policy from different insurance company. On admitting to hospital the complainants wife undergone knee operation. Of the expenses, the another insurance company named Universal Sompo GIC Ltd, had paid Rs.2,50,000/ and remaining amount as Rs. 95,655/ claimed from the opposite party. The claim is not settled or rejected by the opposite party. Hence alleges deficiency in service on the part of the opposite parties. The opposite parties admitting the claim is not repudiated, contends that the complainant not produced the required documents as requested by the TPA called DHS. The settlement of claim is still wide open and will be considered if the complainant produced the documents required by the TPA. The opposite party also put up the contention of non-joiner of necessary parties claiming the TPA is a necessary party. These are being the facts of dispute we are of the view to decide the following
POINTS FOR ADJUDICATION
We have examined the evidence on record and the documents produced by the parties. The admitted facts are, The issue of the mediclaim insurance policy to the complainant, and the treatment taken in the hospital. It is admitted that the complainant has taken two mediclaim insurance policies from two different insurance companies and the one company has approved and paid Rs. 2,50,000/ being the maximum sum assured as cash less treatment and for the balance of the treatment expenses the complainant submitted the claim with the opposite party and the opposite party have neither repudiated nor settled the claim. It is denied that the complainant has produced the required documents to settle the claim, and the opposite parties liability to pay the claimed amount in full. Admissions and denials reconciled and the following points are taken for consideration in resolving this dispute.
- Whether the complainant is the consumer under the consumer protection Act 1986?
- Whether opposite party proves the complainant not produced the required documents and hence the claim is not settled?
- Whether the complainant is entitled for the relief prayed for?
- What order?
On considering the facts and the evidence on record we have taken notes of arguments into consideration and heard the party submissions and answered the above points as under:
- In the affirmative.
- In the negative.
- In the affirmative.
- As per delivered order.
REASON
POINT NO 1: The complainant had produced policy copy as EX C 1which established the purchase of the mediclaim insurance policy from the opposite party and the fact is not disputed by the opposite party. Hence we hold the complainant is a consumer and the opposite party is the service provider and the point no 1 answered in the affirmative.
POINT NO 2: The case of the complainant is on submission of the claim papers for Rs. 95,655/ the opposite party has not honored the claim or repudiated the claim. The opposite party contends the claim is wide open and the complainant not produced the required
documents for settling the claim. Opposite party admits the filing of the claim with documents but submits the TPA had sent a deficiency letter (EX C 7) to the complainant asking for certain documents and the complainant not submitted the documents asked by the TPA. Hence it is the burden of the opposite party to reveal what are the documents still not submitted. Hence the point No 2 is taken for adjudication.
2. On the file record it is found the EX C 7 captioned as deficiency letter in which the TPA called DHS, has requested the complainant to send 6 documents and the complainant answered the said letter EX C 8 and furnished 5 documents and it seems the other documents presumed to be the 2nd document in deficiency letter i.e. attested copies of the claim papers submitted to the another TPA of Universal Sompo GIC Ltd. As seen, the claim papers attested are already in the record. Also the DHS TPA has not come out with any further communication about the insufficiency of the documents produced by the complainant. We presume the TPA of the opposite party is satisfied with what has been sent by the complainant as enclosure to EX C 8 dated 16.04.2014. The contention of the opposite party that the documents required for the claim settlement is not produced by the complainant is not tenable. Hence we hold the opposite party is committed deficiency in service by holding the claim not settled because of without any reason. Hence the point no 2 answered in the negative.
3. The opposite party also raised a point on non-joiner of the necessary parties claiming the TPA is also a party to the dispute. But there is no any privity of contract between the complainant and the TPA. The policy issued by the opposite party and the amount received by the opposite party. Hence there is direct relation of consumer and the service provider is with the opposite party only. We hold the complaint is not suffering from the non-joiner of necessary party.
POINT NO 3: The complainant claimed an amount of Rs.95,655/ as per EX C 2 split into Rs. 73,971/ as balance amount not reimbursed by the Universal Sompo GIC Ltd, Rs.963/ and Rs. 1,521/ as medical bills, and Rs. 19,200/ as physiotherapy. It is argued from the bar that, of the claim made by the complainant with regard to medical bills and the physiotherapy bills are not allowable as the complainant’s wife under gone a package treatment policy for Rs. 3,00,000/ and these expenses are inclusive of the package. The argument is boneless. The physiotherapy is the after operation treatment and the medical bills date is the after the date of operation and cannot be the part of the package. The opposite party not proved it as the expenses included in the package. It is established claim policy that the insurer will reimburse the post operative expenses also for certain period. However the opposite party stated that, the few expenses are not allowable referring to food and beverage expenses in the inpatient bill produced by the complainant. We go with the argument of the opposite party and hold those expenses the opposite party is not liable to pay amounting to Rs. 1,150/ as per EX C 2 page 4. Except these expenses the opposite party is liable for balance
claimed amount. The other arguments from the opposite party with regard to the bifurcation of expenses are trivial. As seen from the EX C 8 page 3 it is the bifurcation of the expenses head wise is sufficiently complied and we do not see any further clarification sought by the opposite party on record. Hence we hold the complainant is entitled for an amount of Rs. 94,505/(claimed amount (...) 1150/) with an interest of 9% per annum from the date of complaint till the date of payment. The opposite party without any cogent reason but imaginary reason of required documents not produced have kept the claim pending for three years is a grave negligence and we allow an amount of Rs. 20,000/ as compensation and Rs. 6,000/ as cost.
POINT NO 4: In the light of the above discussions and the adjudication of above points we deliver the following
ORDER
The complaint is allowed in part. The opposite party shall pay the complainant an amount of Rs. 94,505/ with an interest of 9 % per annum from the date of complaint till the date of payment and an amount of Rs. 20,000/ towards compensation and Rs. 6,000/ as cost within 30 days from the date of the order copy received.
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 typed by Member, revised and pronounced in the open court on this the 12th May 2017)
MEMBER PRESIDENT
(T.C. RAJASHEKAR) (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 : Harischandra D. Suvarna
Documents marked on behalf of the Complainant:
Ex.C1: Copy of policy along with annexures.
Ex.C2: Copy of the claim of the complainant.
Ex.C3: Office copy of the letter issued by the complainant to the Opposite Party dated 28.2.2014.
Ex.C4: 16.4.2014: Office copy of the reminder letter.
Ex.C5: 12.6.2014: Office copy of the lawyers notice.
Ex.C6: Postal acknowledgement, receipt.
Ex.C7: Deficiency letter dated 4.4.2014.
Ex.C8: Copy of complainant letter dated 16.4.2014 with enclosures.
Witnesses examined on behalf of the Opposite Party:
RW1: Mr. Bhavanishankar, Assistant Manager.
Documents marked on behalf of the Opposite Party:
Nil
Dated: 12.5.2017 MEMBER
