BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 31st October 2014
PRESENT
SMT. ASHA SHETTY : HON’BLE PRESIDENT
SMT.LAVANYA M. RAI : MEMBER
COMPLAINT NO.314 2014
(Admitted on 30.8.2014)
Mohammad Rafeeq,
S o Eddinkunhi,
Aged about 34 years,
Rat. Bayabe House,
Kedila Post,
Bantwal Tq., D.K. …….. COMPLAINANT
(Advocate for Complainant: Sri Sanjay D)
VERSUS
The manager,
National Insurance Co., Ltd.,
Dharmasthala Building,
Main road, Puttur, D.K. ……OPPOSITE PARTY
(Opposite Party: Exparte)
ORDER DELIVERED BY HON’BLE PRESIDENT
SMT. ASHA SHETTY:
I. 1. This complaint is filed under Section 12 of the Consumer Protection Act alleging deficiency in service as against the Opposite Party claiming certain reliefs.
The brief facts of the case are as under:
The complainant stated that, he along with his wife Smt Sakeena and three daughters are the holder of Universal Health Insurance Policy as per Policy bearing No. 60230148128500000069 and the policy was valid from 17.4.2012 to 16.4.2013. It is stated that, when the matter stood thus, the complainant’s wife Smt.Sakeena was admitted to the Dhanvanthari Hospital, Puttur on 11.1.2013 for laparoscopic Exploration for left Tubo-Ovarian Mass under GA and discharged on 17.1.2013 and spent Rs.27,245 for operation. Thereafter original bills submitted to the Opposite Party but Opposite Party not reimbursed the medi-claim till this date and hence the complainant filed the above complaint under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Forum to the Opposite Party to pay Rs.27.245 to the complaint with 12% interest from 17.1.2013 till payment to the complainant along with compensation and cost of the proceedings.
II. 1. Version notice served to the Opposite Party by R.P.A.D. Opposite Party inspite of receiving version notice neither appeared nor contested the case before this FORA. Hence, we have proceeded exparte as against the Opposite Party. The acknowledgement marked as Court Doc. No.1.
III. 1. In support of the complaint, Mr.Mohammad Rafeeq (CW1) Complainant filed affidavit reiterating what has been stated in the complaint and documents marked at Ex. C1 to C9. Opposite party placed exparte.
In view of the above said facts, the points now that arise for our consideration in this case are as under
- Whether the Complainant proves that the Opposite Party has committed deficiency in service?
- If so, whether the Complainant is entitled for the reliefs claimed?
- What order?
We have considered the notesoral arguments submitted by the learned counsels and also considered the materials that was placed before this Forum and answer the points are as follows:
Point No.(i) : Affirmative.
Point No.(ii) & (iii): As per the final order.
REASONS
IV. 1. POINTS NO. (i) to (iii):
In order to substantiate the contention raised by the complainant, the complainant (CW-1) filed affidavit supported by documents i.e. Ex.C1 to C9, wherein, it reveals that the complainant and his wife Smt.Sakeena and three daughters are the holder of Universal Health Insurance Policy as per Policy bearing No. 60230148128500000069 and the policy was valid from 17.4.2012 to 16.4.2013 as per Ex. C1. However, the affidavit as well as documents produced by the complainant the Ex. C3 to C5 are the discharge summary and Ultrasonography of Abdomen and medical bills revealed that the complainant’s wife Smt. Sakeena admitted to the Dhanvanthari Hospital Puttur on 11.1.2013 for Laparaoscopic Exploration for Left TuboOvarian Mass under GA and after Operation she was discharged on 17.1.2013 and spent Rs. 27,245 towards medical expenses as per Ex. C4. It also reveals that the complainant submitted the claim form along with copy of the policy and original bills and discharge summary to the Opposite Party through their representation dated 29.1.2013 as per Ex C1. But the Opposite Party not replied nor honoured the claim in this case. As per policy terms and conditions the opposite party is bound to reimburse the medical expenses to the insured but in the instant case the Opposite Party not even bothered to appear before the FORA and not contradictnor controverted the evidence produced by the complainant. The entire evidence placed before the FORA is not challenged by the Opposite Party which requires no further proof. As per the terms and conditions of the policy the opposite party is liable to reimburse the medical expenses spent by the insured. Since the Opposite Party not reimbursed the medical expenses under the policy amounts to deficiency in service as well as unfair trade practice.
In view of the aforesaid reasons, we hold that the Opposite party i.e. National Insurance Co. Ltd., represented by its Divisional Manager is hereby directed to pay Rs.27,245 (Rupees Twenty seven thousand two hundred forty five only) along with interest at 12% per annum from the date of discharge from the hospital till the date of payment to the insuredcomplainant and also pay Rs.2,000 (Rupees Two thousand only) as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.
In the present case, interest considered by this Forum itself is compensation and therefore, no separate amount for compensation is awarded.
In the result, we pass the following
ORDER
The complaint is allowed. Opposite party i.e. National Insurance Co. Ltd., represented by its Divisional Manager shall pay Rs.27,245 (Rupees Twenty seven thousand two hundred forty five only) along with interest at 12% per annum from the date of discharge from the hospital till the date of payment to the insuredcomplainant and also pay Rs.2,000 (Rupees Two thousand only) as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.
Copy of this order as per statutory requirements, be forward to the parties and file shall be consigned to record room.
(Page No.1 to 6 dictated to the Stenographer typed by him, revised and pronounced in the open court on this the 31st day of October 2014)
PRESIDENT MEMBER
