Complaints filed on: 26-04-2022

                                                      Disposed on: 21-01-2023

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, TUMAKURU

#201, 202, 1^st Floor, Indian Red Cross Building Complex,  Ashoka Road, Tumakuru-572 101. 

          DATED THIS THE 21^st DAY OF JANUARY 2023

PRESENT

SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT

SMT.NIVEDITA RAVISH, B.A., LLB. (Spl)., LADY MEMBER

CC.No.85/2022

Sri. Shanthamurthy M S/o Late M.Thippeswamy

Aged about 68 years, R/o Opp. Ganesha Temple,

1^st Main, Girinagar, Kyatasandra, Tumakuru.

……….Complainant

 (By Smt/Kum. Navya .B, Advocate)

V/s

1.       The Manager,

          Bajaj Alliance General Insurance Co. Ltd.,

          Reg. Office:Bajaj Alliance House,

          Airport Road, Yarwada, Punte-411 006.

2.       The Manager,

          Bajaj Alliance General Insurance Co. Ltd.,

          Golden Heights, 4^th Floor, No. ½, 59^th C Cross,

          4^th M Block, Rajajinagar, Bengaluru-560 010.

……….Opposite Party

(OP Sri. N.V.Naveen Kumar, Advocate)

:ORDER:

BY SMT.G.T.VIJAYALAKSHMI, PRESIDENT

This complaint has been filed by the complainant against the OPs U/s 35 of the Consumer Protection Act 2019 with a prayer to direct the OPs to pay the medical bill of Rs.4,10,000/- along with Rs.4,00,000/- towards compensation for mental agony and harassment. 

2.       The brief facts of the complaint are as under:-

The complainant is a retired Employee of Canara Bank and also a member in group Medi-claim policy of Canara Bank customers and accordingly the complainant is customer of OP under Child certificate number OG-22-3233-6021-00000002, under Master policy number OG-20-9999-9960-0000092 and the complainant has paid the final premium of Rs.10,801/- to the OP and the OP also issued policy on 22.04.2021 and the same is valid from 24.04.2021 to 23.04.2022 and sum assured under the policy is 7,50,000/-.  It is further case of the complainant that in the month of July, the complainant suffered from heart problem and was admitted to Manipal Hospitals, Bengaluru, where the complainant undergone for CARDIOTHORACIC SURGERY and admitted for a period of 9 days from 15.07.2021 to 23.07.2021 and then discharged.  When the complainant at Manipal Hospitals, he was given his health card issued by the OP, but the same was not claimed and therefore he has paid the bill amount by borrowing loans from his friends and also from his relatives. 

It is further case of the complainant that it is the legal duty of the OP to pay the Inpatient final bill issued by the said Manipal Hospital as per the insurance taken by the complainant with OP, but the OP did not pay the final bill amount.   It is further contended that in spite of several requests, demands and personal visits and also legal notice issued by the complainant, the OPs did not settle the claim.  Hence, the complainant filed this complaint alleging deficiency in service against the OPs.       

3.       On receipt of notice by this Commission, the OPs appeared through their counsel and filed their version contending that the complainant has taken a MEDICLAIM INSURANCE POLICY vide policy bearing No.OG-22-3233-6021-0000002 valid from 24.04.2021 to 23.04.2022 by paying a premium of Rs.10,801/- for a sum assured of Rs.7,50,000/-.  The policy covers the risk as per the policy terms and conditions.  It is further case of the OPs that they have received a cashless benefit form from the Manipal Hospital on behalf of the complainant and immediately after receipt of the same, the OP has registered the claim, while processing the same this OP has sought some additional information from the hospital authority, and in this regard a letter was sent on 13.07.2021 seeking additional information with regard to

1. Provide clear copy of CAG report,
2. Confirm exact duration of card, heart disease in DD/MM/YYYY Format,
3. Confirm duration of diabetes, hypertension if any,
4. First Consultation paper of Cad

But the said hospital authorities have not furnished the details sought in the letter dated: 13.07.2021.  Hence, with no other alternative, this OP has sent a letter of “denial of cashless facility” on 19.07.2021 stating “general denial clause-3 liability of insurer cannot be ascertained at this juncture.   

It is further contended that after denial also, the complainant has not come forward to provide the details of sought in the letter dated:13.07.2021 and no further claim is registered in this regard and even they wish to state that still the complainant can send a claim intimation in writing along with the documents as per letter dated:13.07.2021 to process the claim in accordance with the policy terms and conditions and therefore the complaint is premature and hence is liable to be dismissed.  The complaint filed by the complainant is not maintainable either in law or on facts.  The complainant has not approached this Commission with clean hands, he has suppressed the material facts and it is a clear case of breach of policy terms and conditions and hence on this ground alone the complaint is liable to be dismissed with costs.  It is further contended by the OPs that the case on hand involves complicated questions of facts and law and hence required voluminous evidence to adjudicate the matter and since this Commission adjudicate the cases on summary trial and hence the complainant has to approach the Civil Court.  On this ground also the complaint is liable to be dismissed.  On these among other grounds, the OPs prayed to dismiss the complaint.

4.       The complainant has filed his affidavit evidence and marked the documents as Ex.P1 to P6.  Smt. Vaishnavai Inamdar, Legal Executive of OP has filed her affidavit evidence and marked the documents at Ex.R1 to R7. 

5.       We have heard the arguments from both side counsels.  We have also gone through the written arguments filed by the complainant.

6.       On perusal of pleadings and documents produced by both parties, the points that would arise for our consideration are:

1)                    Whether there is any deficiency in service on the part of OPs?

2)                     Whether complainant is entitled for reliefs sought for?

7.       Our findings to the aforesaid points are as under:

Point No.1: Partly in the affirmative

Point No.2: As per the final order

:REASONS:

8.       At the outset, it is not in dispute that the complainant has taken a medi-claim insurance policy vide policy bearing No.OG-22-3233-6021-0000002 valid from 24.04.2021 to 23.04.2022 by paying premium of Rs.10,801/- for a sum assured of Rs.7,50,000/-.  In the month of July 2021, the complainant suffered from heart problem and the complainant undergone for CARTIOTHORACIC SURGERY.  The complainant admitted to Manipal Hospital, Bangalore for a period of 9 days from 15/07/2021 to 23/07/2021 and discharged.

9.       Now the main allegation/contention of the complainant is that in spite of several requests, demands and personal visits and for legal notice, the OPs did not pay the inpatient final bill as per the insurance policy.

10.     For the complainant’s allegation, the OP contended that the policy covers the risk as per policy terms and conditions. After receiving the cashless benefit intimation from the Manipal Hospital on behalf of the complainant, the OP registered the claim and while processing the claim, the OP has sought some additional information from the hospital authority and sent letter on 13/07/2021 i.e. Ex.R4 seeking following information:

1. Provide clear copy of CAG report
2. Confirm exact duration of CAD, heart disease in DD/MM/YYYY format,
3. Confirm duration of diabetes, hypertension if any,
4. First Consultation paper of CAD

But the Hospital authorities have not provided/furnished the above information seeking by the OP.  Hence, the OP has sent a letter of “denial of cashless facility” on 19.07.2021 stating “general denial clause-3 liability of insurer cannot be ascertained at this juncture.  Further, the OPs submitted that the complainant can send a claim intimation in writing along with the documents as per letter dated:13.07.2021 to process the claim in accordance with the policy terms and conditions. 

11.     On perusal of Exhibits, it is seen that Ex.P1 related to the Medical bills pertaining to the complainant issued by the Manipal Hospital authorities. As per Ex.R4 the OPs are seeking from the Hospital authorities to furnish some additional information with signature by the treating doctor.  Ex.R3 discloses that hospital authorities submitted the following documents in support of the claim, they are;

1. Detailed discharge summary and bills from the hospital,

2. Cash memos from the hospitals/chemists supported by proper prescription.

3. Receipts and pathological Test Reports from Pathologists, supported by note from the attending Medical practitioner I Surgeon recommending such pathological tests,

4. Surgeon’s certificate stating nature of operation performed and surgeon’s bill and receipt,

5. Certificate from attending medical practitioner/surgeon that the patient fully cured.

In spite of submission of the above documents, again seeking of additional documents with treating doctor signature is not fair on the part of OPs. 

12.     In the course of arguments, the counsel for OP submitted that they are ready to settle the matter as per policy terms and conditions as per prayer in the complaint excluding compensation.  But the counsel for complainant not agreed to settle the matter without compensation.   

13.     The complainant claimed Rs.4,10,000/- for medical expenses and Rs,4,00,000/- claimed for compensation.  The complainant is entitled for Rs.4,10,000/- as per policy and medical bills along with interest @ 9% PA from the date of discharge from the hospital i.e. 23.07.2021 to till realization.  For compensation of Rs.4,00,000/- is concerned, the complainant is not entitled for Rs.4,00,000/-.  In spite of service of legal notice issued by the complainant, the OPs are not come forward to settle the claim of the complainant.  For the negligent act of the OPs, the complainant is compelled to approach this Commission and suffered mental agony.  Hence, the complainant is entitled for compensation of Rs.25,000/- for mental agony suffered and Rs.10,000/- as litigation expenses.   Accordingly, we pass the following:-

:ORDER:

The complaint is allowed in part. 

The OPs are jointly and severally directed to pay to the complainant Rs.4,10,000/- with interest @ 9% PA from the date of discharge from the Hospital i.e. 23.07.2021 to till realization.

The OPs are further jointly and severally directed to pay Rs.25,000/- as compensation and Rs.10,000/- as litigation expenses to the complainant.  

The OPs are directed to comply the above order within 45 days from the date of receipt/knowledge of this order. 

Supply free copy of this order to both parties