Per Sri A. Hazarath Rao, President:-
The complainant filed this complaint U/S 12 of Consumer Protection Act, 1986 seeking reimbursement of Rs.18,817/- incurred towards hospitalization; Rs.50,000/- as damages besides costs.
2. In brief the averments of the complaint are these:
The complainant on 18-10-10 took family health optima insurance policy for himself and his family covering the period upto 17-10-11 for Rs.1,00,000/-. The complainant extended the said policy for further period from 18-10-11 to 17-10-12 for the same amount. The complainant had undergone surgery for ‘Right Inguinal Lipioma’ in Manipal hospitals. The said hospital authorities treated the complainant as in patient on 03-01-12 & 04-01-12. The complainant incurred Rs.18,817/-. The complainant on 06-01-12 submitted claim application along with original documents to the opposite parties. The complainant also approached the 2nd opposite party personally with a request to settle his claim. The attempts of the complainant in settling the claim did not fructify. The attitude of the opposite party in not responding to the claim of the complainant amounted to deficiency of service. The complainant suffered a lot mentally and financially on account of non settlement of his claim by opposite parties.
3. The 1st opposite party filed memo adopting the version of the 2nd opposite party and their contention in nutshell is hereunder:
The complainant intentionally did not refer to the reply given by the opposite parties on 07-05-12. The complainant’s claim was excluded under the policy conditions as the surgery was not on account of disease or accident, vaccination or inoculation. If surgery had been done for cosmetic purpose such surgery was not payble. The opposite parties do not owe any money to the complainant. The opposite parties has rightly repudiated the claim.
4. Exs.A-1 to A-4 were marked on behalf of complainant. No documents were marked on behalf of opposite parties.
5. Now the points that arose for consideration in this complaint are:
1. Whether the opposite parties committed deficiency of service?
2. Whether the complainant is entitled to compensation and
if so to what amount?
6. To what relief?
6. Admitted facts in this case are these:
- The complainant took family health optima insurance policy for Rs.1,00,000/- for himself and for his family members covering the period from 18-10-11 to 17-10-12 (Ex.A-1).
- The complainant submitted his claim to the opposite parties along with relevant documents.
- Exchange of notices between the complainant and the opposite parties (Exs.A-3 and A-4).
7. POINT No.1:- The opposite parties have not denied about the complainant undergoing surgery in M/s Manipal Hospitals for ‘Right Inguinal Lipioma’. The opposite parties relied on clause-8 of policy conditions which reads as follows:
“Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness”.
8. Whether the surgery was excluded or not has to be confronted with the medical reports (Ex.A-2). M/s Manipal Hospital did excision in treating ‘Right Inguinal Lipioma’. The investigation of ultra sound of ‘Right Inguinal Lipioma’ revealed:
“Ultrasound scan of Right Inguinal swelling: Evidence of ~4x3 cm well defined echogenic lesion noted in right inguinal region in subcutaneous plane. The lesion is lobulated with internal septations. Traces of vascularity seen within the septae. The lesion is well encapsulated with no extension in to scrotum – F/S/o? Benign connecting tissue tumor? Lipoma.
On 02-01-2012:
Hemoglobin: 13.5 g/dl/RBS:105mg/dl. Serum Creatinine:1.0 mg/dl. CUE:WNL. HIV I& II : Non Reactive, Hbs Ag: Non Reactive, HCV: Non reactive”.
9. On seeing Ex.A-2 medical history it cannot be said that the complainant underwent circumcision or cosmetic surgery. The opposite parties did not file any cogent evidence to show their contention that they gave reply on 24-01-12 though mentioned in Ex.A-4 repudiation cum reply. The repudiation in our considered opinion is not proper as it did not come under clause (8) of exclusions. Rejecting the claim therefore even if true in our considered opinion amounted to deficiency of service. We therefore answer this point in favour of the complainant.
10. POINT No.2:- The amount of Rs.18,817/- was covered by medical bills. Under those circumstances the opposite parties are liable to make good the loss. The damages/compensation to be awarded should commensurate with the injury complained off. Considering the claim involved awarding Rs.1,000/- as damages in our considered opinion will meet ends of justice. We therefore answer this point accordingly.
11. POINT No.3:- In view of above findings in the result the complainant is partly allowed as indicated below:
- The opposite parties are directed to pay Rs.18,817/- (Rupees eighteen thousand eight hundred and seventeen only) to the complainant together with interest @9% p.a., from 01-02-12 till payment.
- The opposite parties are directed to pay Rs.1,000/- (Rupees one thousand only) as damages.
- The opposite parties are further directed to pay Rs.1,000/- (Rupees one thousand only) as costs.
- The amounts ordered above shall be paid within a period of six weeks from the date of receipt of copy of the order.
Typed to my dictation by Junior Stenographer, corrected by me and pronounced in the open Forum dated this the 7th day of November, 2012.
MEMBER MEMBER PRESIDENT
APPENDIX OF EVIDENCE
DOCUMENTS MARKED
For Complainant :
Ex.No | DATE | DESCRIPTION OF DOCUMENTS |
A1 | 14-10-11 | Copy of policy issued by opposite parties |
A2 | 23-12-12 | Copy of hospital record |
A3 | 21-03-12 | Copy of legal notice got issued by the complainant to the opposite parties |
A4 | 07-05-12 | Reply notice got issued by the opposite party |
For Opposite Parties: NIL
PRESIDENT
