Complaint filed on: 06.07.2011

                                                      Disposed on: 09.12.2016

BEFORE THE IV ADDL DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM,

 1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027       

CC.No.1234/2011

             DATED THIS THE 9^th DAY OF DECEMBER 2016            

PRESENT

SRI.H.Y.VASANTHKUMAR, PRESIDENT

SRI.D.SURESH, MEMBER

SMT.N.R.ROOPA, MEMBER

Complainant: -                     

Sri. Satish

No.813, 4^th Cross,

14^th Main, MEI Layout,

Hesaraghatta Road,

Nagasandra Post,

Bengaluru-560073

By Adv. Sri. B.Jayaprakash

V/s

Opposite parties:-    

1. The Divisional Manager

The Oriental Insurance Company Ltd.,

Divisional Office-13,

Yethiraja Mutt Building,

1^st Floor, 199, 2^nd Main road, Malleswaram,

Bengaluru-560003

By Adv. Sri. Manojkumar M.R

2. M/s Raksha TPA Pvt Ltd

No.25, Ashirwad,

1^st Floor, 29th Main,

4^th B Cross, 2^nd Stage,

BTM Layout

Bengaluru-560076

    Op No.2 - Exparte

ORDER

Under section 14 of consumer protection Act. 1986.

SRI.H.Y.VASANTHKUMAR, PRESIDENT 

          The Complainant has been alleging the deficiency in service against the Opposite party No.1 & 2 in not considering his claim papers for the alleged full amount of Rs.3,47,603/- but for considering it partially for Rs.1,32,071/- and thereby has claimed the compensation with direction to pay the balance amount.

          2. The case of the Complainant in brief is that he being the policy holder of the Opposite party No.1/ Oriental insurance company from 2006, during the 5^th renewal time got the “Happy Family Floater Policy” for the year starting from 15.03.2010 which had the coverage of his family members including his mother Smt.Narasamma. His mother Narasamma was hospitalised in between 10.12.2010 to 21.12.2010 at Panacea Hospital, Basaweshwaranagara, Bengaluru and took treatment at the cost of Rs.3,47,603/-. When he claimed the amount the Opposite party No.1 settled it only for Rs.1,50,000/- as per its letter dated 21.12.2010 addressed to Opposite party No.2. Hence he sent the legal notice dated 19.01.2011 for the full spent amount, that means for the balance amount of Rs.1,97,603/-. Thereafter filed this case.

          3. Opposite party No.2 was placed ex-parte. Opposite party No.1 has questioned the maintainability of this complaint contending that it is filed on erroneous assumption of facts with misconceived ideas to harass the company. The Complainant who had taken individual medi-claim policy from March 2006 to March 2009, later opted for “Happy Family Floater Policy” from 2009 and renewed it in 2010, so as to make it applicable for 5 family members under “Silver Plan” for Rs.5 lakhs each.  The company received the in-patient bill from Panacea Hospital for Rs.1,36,643/-. As per policy terms & conditions by deducting luxury tax and lab test etc., and by considering the conditions as per clause 4.23 that the Complainant to bear 10% of each claim, the bill was cleared. The claimed amount was approved and hence Opposite party No.2 rightly settled the amount for Rs.1,32,071/-. There was no claim for further amount of Rs.1,19,738/-. There is no cause of action for claiming alleged balance amount. In this connection e-mails were sent and received calling for the particulars from Opposite party No.2 and came to know that no claim made for alleged entire amount of Rs.3,47,603/- and hence this complaint is liable to be dismissed.

          4. The Complainant has filed his affidavit evidence relying on Ex-A1 to Ex-A5 documents. The Opposite party official has been examined as DW-1 relying on Ex-B1 to Ex-B35 documents. Arguments were heard.

          5. The consumer disputes that arise for consideration are as follows:

1. Whether the Complainant establishes that the Opposite parties No.1 & 2 have not considered his claim papers properly but settled the amount partially for Rs.1,50,000/- instead of Rs.3,47,603/- and thereby there is deficiency in service by them ?
2. Whether the Opposite party No.1 establishes that they considered the entire claim papers and reimbursed the amount fully to the Complainant ?
3. To what order the parties are entitled ?

6. Answers to the above consumer disputes are as under:

1) Negative

2. Affirmative

3) As per final order – for the following      

REASONS

          7. Consumer Dispute No.1 & 2 : The undisputed facts reveal that the Complainant Satish had taken individual medi-claim policies as per Ex-B1 and also as per Ex-B2, Ex-B3, Ex-B4 subject to terms & conditions as per Ex-B5 for Rs.1,50,000/- each for continuous 3 years with renewal in between 15.03.2006 to 14.03.2009 and he opted/proposed as per Ex-B6 for “Happy Family Floater Policy” as per Ex-B7 & Ex-B9 during the years 15.03.2009 to 14.03.2011 under “Silver Plan” for Rs.5 Lakhs each.

          8. It is also undisputed that among 5 family members mother Smt.Narasamma was also included for the policy benefit. Policies of 4 years up to 2010 are marked as Ex-A1 by the Complainant.

          9. There is no dispute that the mother of the Complainant Smt.Narasamma (ID card Ex-B11) was hospitalised in between 10.12.2010 to 21.12.2010 for which the Complainant has relied on hospital sheets at pages 20 to 91 marked as Ex-A2, wherein the page number 86, 87 hospital bill shows the total amount of Rs.1,32,071/-.

          10. The Opposite party No.1 has contended that the hospital in-patient bill was for Rs.1,36,643/-. The hospital has sent the discharge summary as per Ex-B16, bill as per Ex-B17, Invoice as per Ex-B18 for the same amount of Rs.1,32,071/-. In terms of the policy conditions at clause 4.23 shown as Ex-B8, the Complainant had to bear 10% in each and every claim. The Opposite party No.1 has stated that in terms of the policy the Opposite party No.2 being “third party administrator” rightly settled it for the same amount of Rs.1,32,071/- and accordingly it was approved.

          11. Opposite party No.1 has contended that there is no cause of action for claiming alleged excess amount than the amount of Ex-B16, Ex-B17, Ex-B18 and thereby there is no deficiency in their service also and there is no ground for the Complainant to file this case. In this connection Opposite parties have relied on Ex-B23 to Ex-B35.

          12. The Opposite party No.1 has furnished Ex-B10 requisition letter, Ex-B20 letter dated 27.12.2010, for the  amounts of Rs.24,500/- and Rs.1,32,071/-. Ex-B10 showed as estimated hospital expenses, Ex-B20 showed it as the bill amount with inpatient bill number 36619 which was reflected in Ex-B18 invoice. In Ex-B12 to Ex-B15 e-mails the Opposite party No.2 had sought particulars of the complained disease informing about the terms and exclusions of the policy in December 2010 itself. The said e-mails were relating to the payments of Rs.10,000/-, Rs.5,000/- and Rs.1.50 lakhs.

          13. Ex-B19 relates to the advance amount of about Rs.17,000/-. Ex-B21 hospital letter dated 13.12.2010 shows the acknowledgement for approval of Rs.10,000/- with 10% co-payment, wherein approximation cost of the proposed treatment was shown as around Rs.4,63,500/-. The estimation made on 13.12.2010 was not reflected in bill Ex-B20 dated 27.12.2010, but it was declared as the bill amount of Rs.1,32,071/-.

14. In Ex-B22 legal notice dated 19.01.2011 also there was no mention about documents availed/produced in support of excess amount than the bills and invoices. Legal notice shows that mother Smt.Narasamma was discharged on 22.12.2010 at 7.00pm. The final bill Ex-B20 shows the bill amount of Rs.1,32,071/- as on 27.12.2010. The basis for the alleged amount of Rs.3,47,603/- shown in the complaint and in the legal notice are not supported by any documentary evidence. There is no evidence to show that submitted claim papers were showing the amount exceeding Rs.1,50,000/- or in support of the claimed amount of Rs.3,47,603/-. The estimated cost never become the amount to be claimed from the insurance company without producing any supporting documents.  Nowhere it is stated by the Complainant which of the contents of the documents produced by him were not considered by the Opposite parties. Non-submission of the claim papers from 2006 till the production of the claim papers in 2010 does not empower him to claim the estimated cost. No documentary evidence was placed to show that the Complainant has paid Rs.3,47,603/- towards the said treatment cost to the hospital. The pleadings and the legal notice of the Complainant do not show the alleged payments and differentiation of the same under different heads.

          15. After the receipt of the legal notice Opposite party enquired its officials and Opposite party No.2 by issuing the letters as per Ex-B24, Ex-B25, Ex-B26/B28 sought clarification about the remaining papers which was received by the office about the amount exceeding Rs.1,32,071/-. The Opposite parties issued the reply as per Ex-B26/B28 to the advocate who issued the legal notice seeking advice by him to the Complainant for submission of necessary documents as per the policy conditions for reimbursement of the alleged claim amount. The said covers returned unserved as per Ex-B27, Ex-B28 show that its copy was sent to Complainant also. The Opposite party No.2 has sent the copy of the claim settlement voucher as per Ex-B30 to show that the settlement was done only for the claim of the policy to the extent of Rs.1,50,000/-. The Opposite party No.1 has furnished the medical records submitted to it as per Ex-B31 to Ex-B34 which also do not show the amount exceeding Rs.1,50,000/- nor support the alleged claim of Rs.3,47,603/-. The same was reported by Opposite party No.2 to Opposite party No.1 through Ex-B35 dated 06.09.2011, further intimating that it also has not received reimbursement request from the insured side. All the above documents Ex-B1 to Ex-B35 produced by the Opposite parties show that Ex-B22/Ex-A3 legal notice itself has not provided any such required details.

          16. The careful consideration of the documents of both sides disclose that the complainant had not submitted the claim papers for the amount of Rs.3,47,603/- and his papers even supported by the hospital authorities were restricted to the extent of maximum of Rs.1,50,000/- and the same papers were considered fully subject to the terms & conditions. There is no whisper about the deficiency of service regarding the invoice of the bill as per Ex-B18 and Ex-B20 for Rs.1,32,071/-.The Opposite parties by producing 35 documents have established that the entire claim amount of Panacea Hospital was approved and thereby there is no deficiency as alleged, as it has not left any portion of such papers. The Complainant has failed to establish about the alleged submission of claim papers for the amount of Rs.3,47,603/- and also failed to prove that the Opposite party No.1 & 2 have not considered the papers about the said amount of Rs.3,47,603/-. Thereby the Complainant has failed to establish that the Opposite party No.1 & 2 failed to consider his claim papers properly and thereby the Consumer Dispute No.1 is answered in the negative and the Consumer Dispute No.2 is answered in the affirmative.

          17. Consumer Dispute No.3: In view of the findings of Consumer Disputes No.1 & 2 the Complainant is not entitled to get any relief of his complaint but deserves to get the following:

ORDER

          The Complaint of the Complainant is here by dismissed. No order as to costs.

          Supply free copy of this order to both the parties. 

          (Dictated to the Stenographer, got it transcribed, typed by her/him and corrected by me, then pronounced in the Open Forum on 9th day of December 2016).

Documents marked on behalf of Complainant:

Documents marked on behalf of Opposite party No.1