BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 30th May 2014
PRESENT
SMT. ASHA SHETTY : HON’BLE PRESIDENT
SMT.LAVANYA M. RAI : MEMBER
COMPLAINT NO.70/2013
(Admitted on 16.3.2013)
Rajesh Kumar Jain,
R o Jain Sadan Bhaja Rao,
Lane, Kodialbail,
Mangalore. …….. COMPLAINANT
(Complainant: Appeared in person)
VERSUS
1) The Manager,
T.T.K Health Care TPA Pvt. Ltd.,
Mangalore.
2) Manager,
New India Assurance Co Ltd.,
Centenary Building,
Ganapathi High School Road,
Mangalore. ……OPPOSITE PARTIES
(Advocate for Opposite Party No.1: Sri.Vasudeva Gowda.G)
(Advocate for Opposite Party No.2: Sri.Anil Kumar.K)
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 Parties claiming certain reliefs.
The brief facts of the case are as under:
The complainant stated that, Opposite Party No.2 issued a Medi-claim policy certificate to the complainant bearing policy No. 67080034110300000025, the said policy was valid from 15.2.2012 to 14.2.2013 under the category of the Family Floater Medi-claim for a sum of Rs.3,00,000/- and the said policy covered all the family members of the complainant. It is stated that during the coverage of the policy the spouse of the complainant undergone treatment at K.M.C. Hospital, Mangalore and taken treatment from 17.10.2012 to 18.10.2012. It is stated that, after that the complainant demanded for the settlement of the bill from the Opposite Parties but Opposite Parties denied to settle the amount stating that some concocted stories which is not correct. Thereafter, the complainant sent the representation on 9.11.2011 to the opposite parties but the opposite parties not settled the 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 Parties to settle the claim of Rs.18,000/- along with interest at 12% per annum till realization along with compensation and cost of the proceedings.
II. 1. Version notice served to the Opposite Party NO.1 and 2 by R.P.A.D. Opposite Party No.1 and 2 appeared through their counsel filed separate versions.
Opposite Party No.1 stated that they are only functioning under the company and there is no agreement between the complainant and this Opposite Party and prayed for dismissal of the complaint.
Opposite Party No.2 stated that in the policy clause No.4.4.11 of the said policy the expenses incurred at the hospital or Nursing Home for diagnostic, X-ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which is required at a hospital/Nursing Home. After applying its mind to the above clause the opposite party has repudiated the claim and intimated the complainant accordingly and contended that the opposite party No.2 is not liable to indemnify the expenses incurred by the complainant and prayed for dismissal of the complaint.
III. 1. In support of the complaint, Mr.Rajesh Kumar Jain (CW1) – Complainant filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on him and produced Ex. C1 and C2. On behalf of Opposite Parties one Sri. Sheshappa Naik.M (RW-1) Administrative Officer of O.P.No.2 filed counter affidavit and answered the interrogatories served on them and produced Ex.R1 to R5.
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 Parties have committed deficiency in service?
- If so, whether the Complainant is entitled for the reliefs claimed?
- What order?
We have considered the notes/oral 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 the instant case, the facts which are admitted is that the complainant is the medi-claim policy holder bearing No. 67080034110300000025 for a sum Rs. 3,00,000/-, the said policy was valid from 15.2.2012 to 14.2.2013. It is also not in dispute that the complainant paid a basic premium amount of Rs.4,170/- plus Rs.2,085/- as floater extra for spouse 50%. In addition to that the complainant also paid floater extra for children 25% in total the complainant a premium of Rs.8,341/- for a sum of Rs.3,00,000/-. It is also admitted during the period of existence of the policy the spouse of the complainant undergone treatment at KMC Hospital, Mangalore and admitted as inpatient and taken treatment from 17.10.2012 to 18.10.2012 and during the treatment she was medically examined by conducting several test including MRI brain with GADO at Balmatta Scan Centre.
Now the points are in dispute before this FORA is that, the complainant contended that the medical expenses spent for the treatment has not been reimbursed by the Opposite Parties. Hence came up with this complaint.
On the other hand Opposite Party contended that the claim of the complainant falls within the exclusion clause No.4.4.11 under the policy. Hence they are not liable to reimburse the medical expenses.
On perusal of the oral as well as documentary evidence available on record, we find that, during the existence of the policy the spouse of the complainant taken treatment. However, the policy i.e. Ex.R1, wherein clause No.4.4.11 reads as under:-
“Expenses incurred at the hospital or Nursing Home for Diagnostic, X-ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which is confinement is required at a hospital/Nursing Home.”
Opposite Parties contended that the complainant’s wife undergone tests and diagnosis to ascertain the existence of the ailment and she has not undergone treatment for any ailment and further contended that the complainant was presented with the complaints of headache and visual blackouts since four months and diagnosed as benign intracranial hypertension and during the hospitalization only investigations are done and treated with the oral medications for which hospitalization as an inpatient was not necessary as same could have been on out patient basis. The contentions taken by the Opposite Party company is nothing but perverse because whatever the test and diagnosis undergone by the complainant’s wife as per the advice of the treating doctor in order to diagnosis the ailment already suffering by her. In order to ascertain the final diagnosis, certain tests/diagnosis are very much required. Therefore, the Opposite Party company cannot deny the claim of the complainant raising a contention that it is not the consistent with or incidental to the diagnosis of the positive existence and treatment of any ailment seeking or injury. The document produced by the parties i.e. discharge summary, test report, MRI scanning report are reveals that the doctor is adviced to undergo those examinations/tests in order to ascertain the ailments even though the said ailments are not connected with the one which suffering ailments. Even the patient has to take inpatient or outpatient treatment is to be decided by the treating doctor and not the other persons. Therefore, we are of the opinion that the interpretation of the clauses mentioned in the policy taken into broad conception not within but not narrowing down the claim of the insured persons. Because the insured persons are not aware, in other words the insured are not intended to undergo any tests or diagnosis as per their whims and fancies. On the other hand, those tests were undergone as per the advice of the treating doctor in connection with the treatment. Therefore, the Opposite Parties cannot take shelter under the exclusion clause in this case and the opposite parties are liable to reimburse the medical expenses spent by the complainant’s wife. By considering the above aspect we hold that the service rendered by the opposite party company deficiency in service as well as unfair trade practice.
In view of the aforesaid reason, the Opposite Party No.2 is hereby directed to pay Rs.18,000/- (Rupees Eighteen thousand only) to the complainant’s wife along with interest at 12% per annum from the date of discharge from the hospital till the date of payment and also pay Rs.2,000/- (Rupees Two thousand only) as costs of the litigations expenses. Payment shall be made within 30 days from the date of this order. Since there is no contractual obligations between the complainant and the opposite party No.1, the complaint against Opposite Party No.1 is hereby dismissed.
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 No.2 i.e. New India assurance Co. Ltd., represented by its Divisional Manager shall pay Rs.18,000/- (Rupees Eighteen thousand only) to the complainant along with interest at 12% per annum from the date of discharge till the date of payment and also pay Rs.2,000/- (Rupees Two thousand only) as costs of the litigations expenses. Payment shall be made within 30 days from the date of this order.
Complaint against Opposite Party No.1 is hereby dismissed.
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 8 dictated to the Stenographer typed by him, revised and pronounced in the open court on this the 30th day of May 2014)
PRESIDENT MEMBER
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 – Mr.Rajesh Kumar Jain – Complainant.
Documents produced on behalf of the Complainant:
Ex C1: 9.11.2012: Representation given by the complainant to the O.P.
Ex C2: 2.11.2012: Claim acknowledgment issued by the O.P.
Witnesses examined on behalf of the Opposite Parties:
RW-1: Sri. Sheshappa Naik.M, Administrative Officer of O.P.No.2.
Documents produced on behalf of the Opposite Party:
Ex R1: Family Floater Mediclaim policy.
Ex R2: Discharge Summary issued by KMC Hospital, Mangalore.
Ex R3: Test Report.
Ex R4: 16.10.2012: MRI scanning report.
Ex R5: Medical & Hospital bills.
Dated:30-05-2014 PRESIDENT
