Date of Filing: 21.12.2010
Date of Order: 25.05.2011
BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SESHADRIPURAM BANGALORE-20
Dated: 25TH DAY OF MAY 2011
PRESENT
Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.
Smt. D. LEELAVATHI, M.A.LL.B, Member.
Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.
COMPLAINT NO: 2969 OF 2010
Nalini N.
49/41, 5th Cross
CAD School Building
Venkatapura, Koramangala
Bangalore 34 Complainant
V/S
1. The Manager
TATA AIG Life Insurance
Gr. Floor, 474, 6th Block
80 feet Road, Koramangala
Bangalore 94
2. Raksha TPA Pvt. Ltd.
25, Ashirwad, 29th Main
4th ‘B’ Block, BTM Layout
2nd Stage, Bangalore 76 Opposite Parties
ORDER
By the Member Sri Balakrishna. V. Masali
The brief facts of the case are that complainant had taken a medical health policy from the TATA AIG Life Insurance Co. Ltd. vide policy No. C192216540 on 27.07.2009 to get the treatment under cashless. At the time of taking up the said policy complainant was informed by the TATA AIG Life Insurance Co. Ltd. that all Hospitalization Expenses would be covered in case of any hospitalization. The complainant had called up Raksha TPA to check on the cashless facility and they guided and told to get admitted in Wockhardt Hospital in order to get a full cashless facility. As per the advice given by Raksha TPA complainant was hospitalized at Wockhardt Hospital at Bangalore between 11.12.2009 to 18.12.2009 for intestinal infection and undergone diagnostic Laproscopy adhesiolysis incidental appendicectomy under general Anesthesia on 17.12.2009 as per discharge summary. After Hospitalization complainant had sent her claim on 22.04.2010 for Rs.1,50,000/- as medical expenses incurred in the said Hospital. But the opposite party company rejected claim as the above said surgical procedures are not covered under any of 92 surgeries listed under the policy. The opposite party company has honoured their part of the contract by conferring benefits of the daily hospitalization i.e. Rs. 750/- per day for 7days i.e. Rs. 5,250/- and sent a cheque for the said amount to complainant which is not acceptable. Due to misguidance of the opposite party and its agent complainant incurred a sum of Rs. 1,50,000/- for the said Medical Treatment. Complainant has borrowed the said amount from her friends. Complainant pray that this Hon’ble forum be pleased to direct the opposite parties to pay the sum of Rs. 1,50,000/- along with compensation for mental agony. Hence, the complaint.
2. Notice was issued to the Opposite Party. The Opposite party put in appearance through advocate and filed defence version. In the defence version it is submitted that all the allegations and averments made in the complaint are denied as baseless, false and frivolous unless specifically admitted. The complainant was hospitalized at Wockhardt hospital at Bangalore between 11.12.2009 to 18.12.2009 for intestinal infection and seems to have undergone diagnostic Laparoscopy adhesiolysis and incidental appendicectomy under general anesthesia on 17.12.2009. The Complainant made a claim for reimbursement at Rs. 1.5 lakhs towards the expenses incurred during the hospitalization. The opposite party validly rejected the claim as the above said surgical procedures are not covered under any of the 92 surgeries listed under the Policy. Moreover the ailment of the complainant cannot be termed as “Critical Illness” under the policy as 180 days have not expired since the policy was issued to the Complainant. However, the Opposite party company has honoured their part of the contract by conferring benefit of the daily hospitalization i.e. Rs. 750/- per day for 7days, Rs. 5,250/- and sent a cheque bearing No. 594535 dated 05.05.2010 drawn on HDFC Bank ltd. Mumbai. Complainant has thoroughly read the policy document and only thereafter, she has signed and taken the policy with Opposite Party Company. Hence, she is bound by the terms and conditions of the policy document that the complainant has filed their complaint without any valid ground and trying to make unjust enrichment at the cost of the Opposite party company. Hence, dismiss the complaint with cost.
3. Affidavit evidence of parties filed.
4. Arguments are heard.
5. The points for consideration are:
Whether there was deficiency of service on the part of opposite parties?
REASONS
6. The Opposite party No.1 admitted that the complainant has taken the “Health First” Mediclaim policy from the opposite party No.1 bearing policy No. C192216540 on 27.07.2009. The Complainant was hospitalized at Wockhardt Hospital at Bannerghatta Road, Bangalore between 11.12.2009 to 18.12.2009 for Intestinal infection and seems to have undergone diagnostic Laparoscopy adhesiolysis and incidental appendicectomy under general Anesthesia on 17.12.2009 as per discharge summary at the said Hospital. Thereafter, the complainant made a claim for reimbursement of Rs. 1.5 lakhs towards the expenses incurred during the Hospitalization. But, the opposite party No. 1 validly rejected her claim as the above said surgical procedures are not covered under any of 92 surgeries listed under the policy and under the policy as 180 days have not expired since the policy was issued to the complainant. The opposite party No. 1 has honoured their part of the contract by conferring benefits of the daily hospitalization i.e. Rs. 750/- per day for 7 days Rs. 5,250/-. The opposite party No. 1 has produced document No. 1. As per document the said surgical procedures are not covered under any of 92 surgeries listed under the policy. The complainant has been hospitalized at Wockhardt Hospital at Bangalore between 11.12.2009 to 18.12.2009. Therefore, the opposite party No. 1 has honoured their part of the contract by conferring benefits of the daily hospitalization i.e. Rs. 750/- per day for 7 days Rs. 5,250/-. So under these circumstances it is just, fair and reasonable to order the opposite party No. 1 to settle her claim. In the result I proceed to pass the following:
ORDER
7. The complaint is allowed. The opposite parties No. 1 is directed to pay Rs. 5,250/- to the complainant. The opposite party No. 1 shall comply the order within 30 days from the date of the order.
8. The complainant is also entitled for Rs. 2,000/- as costs of the present proceedings from the opposite party No. 1.
9. The opposite party is directed to send the amount directly to complainant by way of D.D. / cheque with intimation to this forum.
10. Send the copy of this Order to both the parties free of costs immediately.
11. Pronounced in the Open Forum on this 25TH DAY OF MAY 2011.
Order accordingly,
MEMBER
We concur the above findings.
MEMBER PRESIDENT
