COMPLAINT FILED: 13-04-2010 <br /> DISPOSED ON: 08-07-2010<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> 8TH JULY 2010<br /> <br /> PRESENT :-SRI. B.S.REDDY PRESIDENT <br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI.A.MUNIYAPPA MEMBER <br /> COMPLAINT NO.814/2010<br /> <br /> COMPLAINANT <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Mrs. Runa Mukherjee,<br /> W/o.Mr.R.Mukherjee,<br /> Resident of No.601,<br /> Brigade Paramount,<br /> Nagavarapalya,<br /> C.V.Raman Nagar Post,<br /> Bangalore – 560 093.<br /> <br /> Advocate – R. Santhosh Kumar<br /> <br /> V/s.<br /> <br /> OPPOSITE PARTIES 1. The Manager,<br /> M/s. E-Mediteck Solutions <br /> Ltd.,<br /> No.36/1, Dickenson Road,<br /> Bangalore- 560 042.<br /> <br /> 2. The Divisional Manager,<br /> M/s. United India Insurance <br /> Co. Ltd.,<br /> No. III, Classic Road,<br /> Bangalore – 560 025.<br /> <br /> Ex-parte <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> O R D E R<br /> <br /> <br /> SMT. M. YASHODHAMMA, MEMBER<br /> <br /> This is a complaint filed u/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction against the Opposite Party (herein after called as O.P) to settle the claim of Rs.1,50,000/- and to pay compensation of Rs.50,000/- and costs on the allegations of deficiency in service. <br /> <br /> 2. The brief averments made in the complaint are as follows:<br /> <br /> Complainant had obtained a cancomfort health insurance policy bearing No: 70300/2009-10/00380/01 from OP. OP had under taken to bear and pay the medical expenses incurred by the complainant during the subsistence of the insurance. Complainant had some eye problem, to cure the same she had to undergo eye treatment of Intra vitreal Injee, LUCENTIES-TA-Left Eye. During the month of August 2009, complainant before undergoing the said treatment consulted Dr. Prakash of E-Mediteck Solutions Ltd.,. Dr. Prakash consented for the eye treatment and confirmed that the complainant is entitled for the benefit of Policy. First complainant has to bear the entire cost from her pocket for treatment and on Submission of bills and Medical reports, entire amount would be reimbursed by E-Mediteck. Accordingly complainant under went Intra vitreal Injuee, LUCENTIES-TA for her left eye at Nethradhana Hospital Pvt. Ltd., at Jayanagar, Bangalore on 08.08.2009, 09.09.2009 and 08.10.2009 (three sittings) and spent Rs.1,50,000/- for the said treatment. Entire bills and medical reports submitted to the 1st OP’s office. Same was brought to the notice of 2nd OP. There was no response. OPs have completely neglected to honour the legitimate claim of the complainant. Neither settling nor stating any reason for non-settlement of complainant’s claim, inspite of repeated phone calls and letters. Hence complainant caused Legal Notice on 09.02.2010. Head office of OP-2 gave the reply stating they will undertake to settle the matter by taking up the matter with the concerned. But till today there was no response. Hence complainant felt deficiency in service on the part of the OP. Under these circumstances she is advised to file this complaint for the necessary reliefs.<br /> <br /> 3. On registration of the complaint notices were sent to OPs. Inspite of service of notice OP 1 and 2 remained absent without any sufficient reason or cause. Hence OP’s are placed ex-parte.<br /> <br /> 4. To substantiate the complainant averments, complainant filed her affidavit evidence and produced Insurance certificate, Doctor’s report, discharge summary, medical bills, claim form, copy of legal notice, reply of OP-2 and submitted written arguments. Heard the oral arguments of the complainant.<br /> <br /> 5. It is contended for the complainant that she had obtained a concomfort health insurance policy bearing No. 70300/2009-, 10/00380/01 which is inforce from 01.11.2008 to 31.10.2009. Wherein OP has undertaken to bear the Medical expenses incurred by the complainant during the subsistence of the Insurance. Complainant had some eye problem. She was advised to undergo treatment of Intra Vitreal Injee, LUCENTIES-TA-Left eye, during the month of August 2009. After consulting Dr. Prakash of OP-1 on 04.08.2009, who in turn assured the complainant, that the Policy covers the said treatment and complainant is entitled for the benefits of the Policy, Complainant underwent treatment at Nethradhana Hospital Pvt. Ltd., at 7th Block Jayanagar, Bangalore for Intra Vitreal Inj Lucentis-Gvp-TA for the left eye on 08.08.2009/09.09.2009 and 08.10.2009 (Three siltings) by Dr. Chandra Kumar. Documents to that effect are produced; complainant claimed Medical reimbursement of Rs.1,50,646/- from OP. There was no response from OP. Hence complainant caused legal notice on 09.02.2010. Head office of OP-2 gave the reply on 02.03.2010 stating they are taking up the matter with their Regional office, and OP-1 to know about the reason for non-settlement of claim. But there was no response from OPs. Complainant filed this complaint on 13.04.2010 before this Forum. <br /> <br /> 6. When policy is in force, as per the terms of the policy complainant is entitled for reimbursement of medical expenses. Claim neither settled nor repudiated by OP amounts to deficiency in service on the part of the OPs. In the matter of M/s. Golden Trust Financial Service and Another V/s. Malwa Devi reported in 2009(1) CPJ 264 Hon’ble Jharkhand State Commission held that the claim submitted by the complainant was neither settled nor repudiated/disclaimed by the Insurance Company. The Insurance Company therefore was certainly deficient in service in not settling the claim of the complainant and not making payment of Insurance amount to her. We have perused the complaint averments. Unchallenged affidavit evidence and documents. The documents produced by the complainant corroborates the case of the complainant. Absence of OP’s before this Forum inspite of service of notice leads us to draw an inference that OPs admits all the allegations made by the complainant in toto. We are satisfied that complainant has proved the deficiency in service against OP’s. Under the circumstance we are of the considered view that an opportunity is to be given to OP to consider the claim of the complainant. Accordingly we proceed to pass the following:<br /> <br /> <br /> <br /> <br /> ORDER<br /> <br /> The complaint is allowed in part. OP-1 & 2 are directed to consider the Medical reimbursement claim of the complainant within 30 days from the date of communication of this order. Further complainant is at liberty to approach this Forum if he is not satisfied with the settlement.<br /> <br /> <br /> (Dictated to the Stenographer and typed in the computer and transcribed by her verified and corrected, and then pronounced in the Open Court by us on this the 8th day of July 2010.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> <br /> gm<br />