Complaint filed on: 25-10-2017
Disposed on: 23-10-2018
BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM,
OLD DC OFFICE COMPOUND, TUMAKURU-572 101
CC.No.95/2017
DATED THIS THE 23rd DAY OF OCTOBER 2018
PRESENT
SMT.PRATHIBHA. R.K. BAL, LLM, PRESIDENT
SRI.BALAKRISHNA V.MASALI, MEMBER
Complainant: -
M.S.Ramachandra,
S/o. Late M.R.Subbarao,
Aged about 55 years,
R/at Sri Krishna Nilaya,
Behind Nalanda Convent,
Raghavendra Nagara,
Tumakuru
(By Advocate Sri.Ramesh.S)
V/s
Opposite parties:-
- The Manager,
The Oriental Insurance
Co. Ltd, Registered office:
The oriental house,
P.B.No.7030, A-25/27,
Asafali Road, New Delhi-02
- Divisional Manager,
The Oriental Insurance
Co. Ltd, Division office,
No.1001/56, Jayalakshmi Mansion, 2nd Floor,
4th Flock, Dr.Rajkumar
Road, Rajajinagar,
Bengaluru-10
- The Manager,
The Oriental Insurance
Co. Ltd, TGMC Building,
1st floor, JC Road,
Tumakuru-01
- The Manager,
Good Health,
TPA Services, Plot No.49, Nagarajuna Hills,
Panjagutta, Hydarabad-82
(OP No.1 to 3 – by advocate
Smt.Inderamma.B.S)
(OP No.4 – Exparte)
ORDER
SMT.PRATHIBHA. R.K., PRESIDENT
This complaint is filed by the complainant against the Opposite party No.1 to 4 (herein after called as OPs), under section 12 of the Consumer Protection Act, 1986. The complainant prays to direct the OP No.1 to 4 to pay the balance bill amount of Rs.41,735=00 and grant such other relief as prayed in the complaint, in the interest of justice and equity.
2. The brief fact of the complaint is as under.
The complainant had purchased “Silver Gold” policy bearing No.423201/48/2014-973 from the OPs. The above said policy was covering the risk for his family members i.e. his wife and two children. The risk coverage amount of the above said policy is Rs.3,00,000=00.
The complainant submitted that, after purchase of the above said policy, the complainant had paid the renewal amount to the OPs to get renewal of the policy every year. As per the terms and conditions of the policy, the OPs have agreed to pay the risk coverage amount as per the clause 1.2 and 1.3.
The complainant further submitted that, the above said policy is cashless policy. The insurer is eligible to get the treatment by admitting as an inpatient in any hospital recognized and affiliated to the OPs Company.
The complainant further submitted that, the complainant’s son by name M.R.Atheeth was admitted as an inpatient in the BGS Global Hospital, Bengaluru for the treatment of Acute Hepatitis Viral, and he has taken treatment in the said hospital as inpatient and discharged on 25-7-2016. The said hospital was investigated the patient and took the treatment. Thereafter, the complainant had approached the OPs Company along with investigation report and discharge summary together with medical expenses bill amount of Rs.80,000=00 for reimbursement.
The complainant further submitted that, the complainant had submitted the medical expenses of Rs.80,000=00 to the OP Company. The OPs Company had paid only Rs.38,268=00 as settlement amount.
The complainant further submitted that, as per the terms and conditions of the policy, the OPs Company is liable to pay the medical expenses of Rs.80,000=00 to the complainant as he has obtained a cashless policy. In this regard, the complainant has made written requests to the OPs along with documents for reimbursement of full amount as per the terms. But the OPs have not replied to the said requests nor make the payment. Hence, the OPs have breached the terms of the policy and there is deficiency of servcie on the part of the OPs by adopting unfair trade practice. The complainant has issued legal notice dated 23-3-2017 and 27-3-2017 to the OPs calling upon them to pay the balance amount. The said notices were duly served on the OPs, but the OPs have not replied to the notice. Hence, the complainant has come up with the present complaint.
3. After service of notice, the OP No.1 to 3 have appeared through their counsel and filed version. The 4th OP has not appeared before the forum and he was called out absent and he has been placed exparte.
4. In the version, the OP No.1 to 3 submitted that, the complaint is not maintainable either in law or on facts and it is liable to be dismissed in limine. The OP No.1 to 3 submitted that, the complainant had purchased Happy Family Floater Policy Silver Plan; vide policy no.423201/ 48/2014/973. The risk coverage amount in the policy is Rs.3,00,000=00 with agreed terms and conditions by the complainant.
The OP No.1 to 3 further submitted that, at the time of obtaining the policy, the complainant has agreed the terms and conditions of the policy. As per the terms and conditions of the policy column No.1.2, the policy limit of reimbursement not exceeding 1% of the sum insured per day. As per calculated the amount, which will be reimbursed to the complainant, only after calculating the amount, the OPs have paid the amount of Rs.38,268=00. Hence, the question of paying the balance amount in Rs.80,000=00 has not arised. The OPs or their agents have not informed about the entire reimbursement of medical expense incurred by the complainant.
The OP No.1 to 3 further submitted that, the complainant had received the part amount in the year 2014 and he kept quiet for a period of two years. Thereafter, all of a sudden thought, the complainant filed the present complaint. Hence, there is no cause of action to file the complaint and there is no deficiency in service on the part of the OPs. All other allegations made in the complaint are denied as false. Hence, the OPs have prayed to dismiss the complaint with cost, in the interest of justice and equity.
4. In the course of enquiry in to the complaint, the complainant and OPs have filed their affidavit evidence reproducing what they have stated in their respective complaint and version. Both parties have produced documents which were marked as Ex-P1 to P17 and Ex-R1 to R4. We have heard the arguments of both sides and we have gone through the oral and documentary evidence of both parties scrupulously.
5. Based on the above materials, the following points arise for our consideration;
1. Whether the complainant has proved there is deficiency in service on the part of the OPs?
2. What order?
6. Our findings on the above points are as under:
Point No.1: In the affirmative
Point No.2: As per order below
REASONS
7. On perusal of the averments of the complaint, objection of the OPs and affidavit evidence of both parties, it is an admitted fact that, the complainant had purchased Happy Family Floater policy bearing No.423201/48/2014-973 from the OPs. It is also admitted fact that, the above said policy is Silver Gold Plan policy.
8. The OPs have raised a preliminary objection that, the present complaint is barred by limitation. Since, the complainant has received a part amount from the OPs in the year 2014. The complaint is filed by the complainant in the year 2017. Hence, the complaint is not maintainable as per CP Act. On perusal of the documents produced by the complainant i.e. Ex-P15/ letter dated 18-8-2016 issued by the OPs. The complainant’s son was admitted to the hospital on 20-7-2016 and discharged on 25-7-2016. The OPs have paid an amount of Rs.38,265=00 on 18-8-2016. Hence, the complainant has filed this complaint within the limitation period as per Section 24 (A) of the CP Act.
9. Further, the OPs have taken contention that, as per the terms and conditions policy No.1.2 coverage under the policy limit of reimbursement, not exceeding 1% of the sum insured per day. As per that calculated amount i.e. 1% of the sum insured is Rs.3,00,000=00 is Rs.3,000=00 and the OPs have paid Rs.15,000=00 towards room rent charges for a period of 5 days. Similarly consultation fee and laboratory charges are calculated as per the room category as the complainant has admitted in the hospital. Hence, the OPs have paid Rs.38,268=00 out of Rs.80,000=00 of the claim amount.
10. To substantiate the above said facts, the OPs have produced policy copy/Ex-R1, terms and condition of the policy/Ex-R2 and letter dated 18-8-2016 issued by the OPs to complainant/Ex-R4 is the copy of settlement of the amount by the OPs.
11. On perusal of the Ex-R4 and Ex-P15, wherein it is mentioned that, room-rent charge claimed amount is Rs.28,800=00 and deducted amount is Rs,13,800=00 and sanctioned amount is Rs.15,000=00. In the remark column, it is mentioned that, 1% SI room-rent restricted. Laboratory claimed amount is Rs.37,430=00 and deducted amount is Rs.17,835=00 and sanctioned amount is Rs.19,495=00. In the remark column, it is mentioned that, paid as per entitled room category.
12. On perusal of the terms and conditions of the policy No.1.2 – Silver plan in the benefits head, wherein it is written as “Not exceeding 1% of the sum insured per day” As per Silver Plan, the OPs have deducted the amount and paid the room-rent charge of Rs.15,000=00.
13. On careful observation of the policy No.1.2, nowhere it is mentioned that, the expenses of the consultants and laboratory charges shall be payable as per room rent category. Hence, the OPs have illegally deducted the consultant charges of Rs.4,274=00 and laboratory charges of Rs.17,935=00. Moreover, the OPs have not produced any documentary evidence to prove that, the consultants and laboratory charges of the hospital, on the basis of room rent category. In the above said facts, we are of the opinion that, the OPs have illegally deducted the consultants and laboratory charges in the claimed amount. Hence, it is just and proper to direct the OPs to reimburse the deducted amount of Rs.4,274=00 and 17,935=00 towards consultants and laboratory charges to the complainant. Further the OPs are directed to pay compensation of Rs.10,000=00 and litigation cost of Rs.5,000=00 to the complainant. Accordingly, we answer the point No.1 in the affirmative. In the result, for the foregoing reasons, we proceed to pass the following order.
ORDER
The complaint filed by the complainant is allowed.
The OP No.1 to 4 are jointly and severally directed to reimburse the deducted amount of consultants charge of Rs.4,274=00 and laboratory charges of Rs.17,935=00 to the complainant within 30 days from the date of this order, failing which, the OPs shall pay the above said amount to the complainant along with 9% interest from the date of this order to till the date of realization.
Further the OP No.1 to 4 are jointly and severally directed to pay compensation of Rs.10,000=00 and litigation cost of Rs.5,000=00 to the complainant.
This order is to be complied by the OP No.1 to 4 within 30 days from the date of this order.
Supply free copy of this order to both parties.
(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open forum on this, the 23rd day of October 2018).
MEMBER PRESIDENT
