Date of Filing : 26.06.2012
Date of Order : 18.08.2012
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KOLAR
Dated 18th AUGUST 2012
PRESENT
Sri. H.V. RAMACHANDRA RAO, B.Sc., BL, ……. PRESIDENT
Sri. T.NAGARAJA, B.Sc., LLB. …….. MEMBER
Smt. K.G.SHANTALA, B.A., LLB. …….. MEMBER
CC No. 78 / 2012
Sri. S.G. Manjunath,
S/o. S. Gopala Krishna,
Aged about 28 years,
Door No. 5/132, Kandavarpet,
Chickballapur – 562 101. ……. Complainant
V/s.
1. The National Insurance Co. Ltd.,
Kolar Branch, No. 1092/2,
New Extension, Near Doom Light Circle,
Kolar.
2. The M.D. India Health Care Service (TPA)
Pvt. Ltd., S. No. 46/1, E-Space, A-2 Wing,
3rd Floor, Pune Nagar Road, Vadgaonsheri,
Pune – 411 014. …… Opposite Parties
ORDER
By Sri. H.V. RAMACHANDRA RAO, PRESIDENT
The brief antecedents that lead to the filing of the Complainant made u/s. 12 of the C.P. Act seeking direction to the OP to pay to the Complainant Rs.22,810/- are necessary:
As per the Order in CC No. 218/2010 (218/2011) made by this Forum on 26.03.2012, Complainant has produced all the relevant documents to the OP1 and claimed Rs.30,567/-. It was processed by TPA of OP and approved for Rs.15,567/- and Cheque dtd. 16.04.2012 was issued to the Complainant. Balance of Rs.15,000/- towards Bill Nos. 4649/12.06.2011, 4667/17.06.2011, R.B. 2011188337, Bill No. 41128, Bill No. 2461, Bill No. 37691, Bill No. 38113/20.07.2011, Ambulance Bill No. 326 balance, Bill No. 343 (balance), Bill No. 817 (balance) &Advocate’s fees has not been paid. Hence the Complaint.
2. OP2 though served remained absent throughout the proceedings. In brief the version of OP1 are:-
There is no privity of contract between the parties. Order in CC No. 218/2011 and the claim is admitted. OP after processing the entire documents has sanctioned Rs.15,567/- and it was paid by Cheque dtd. 16.04.2012. Rest of the amount has been rightly disallowed. Original documents were also returned to the Complainant.
3. To substantiate their respective cases, OP1 has filed its affidavit. Complainant’s Counsel has stated that his Complaint and documents be read as his evidence and also filed written arguments. Arguments of both the Counsels were heard.
4. The points that arise for our consideration are:
(A) Whether there is deficiency in service ?
(B) What order ?
5. Our findings are:
(A) Positive
(B) As per detailed order for the following reasons
REASONS
6. Points (A) & (B) – Reading the pleadings in conjunction with the affidavit and documents on record, it is an admitted fact that the Complainant had filed Complaint No.218/2011 before this Forum seeking direction to the OP to pay Rs.1,00,000/- regarding medical policy. In that regard this Forum after contest on 26.03.2012 has passed an Order. The relevant portion of the Order reads thus:
“6. Reading the pleadings in conjunction with the documents and the affidavit on record, it is an admitted fact that the Complainant had obtained Mediclaim Policy from the Ops. Regarding certain medical treatment, Complainant has claimed the amount from the Ops and the Ops wanted original medical certificates etc. from the Complainant and on scrutiny of those original documents they are going to honour the claim or reject the claim as the case may be. The original documents are not furnished yet.
7. The apprehension of the complainant is that since they have claimed compensation under MVC, they are required to submit original documents to the MVC Tribunal constituted under the MVC. Anyway, during the course of the arguments, it was suggested to the Counsel for the Ops to receive all the original documents from the Complainant now before the Forum, scrutinize the same and pass appropriate orders and return all the documents to the Complainant for which the Counsel for the Ops have readily agreed. The statement is recorded.
8. Hence, we hold point accordingly and pass the following Order.
ORDER
1. Counsel for the Complainant is directed to deliver all the original documents with list to the Counsel for the Ops before this Forum.
2. Ops shall process the claim of the Complainant within 30 days from today and pass appropriate orders and return all the original documents to the Complainant keeping the copies thereof with it within 30 days from today.
3. In case of order is going against the Complainant, he is at liberty to move the Forum as it deemed fit.”
7. It is also an admitted fact that OP2 is the TPA of OP1 who is the insurer. On receipt of the claim, OP1 has issued Cheque for Rs.15,567/- only though the Complainant had laid the claim for Rs.30,567/-. Relevant portion of the Order that has been passed by the OP1 reads thus:
This refers to your claim under policy No. 604102/48/10/ 8500000505 for Rs.30,567/-. In pursuant to the Forum order dated 26/03/2012 the claim is processed by TPA and it is approved for Rs.15,567/- towards the full and final settlement of the said claim. The Cheque no. 1171122 dated 16/04/2012 drawn in favour of Sri S.G. Manjunath payable at par by Bank of India is enclosed herewith along with Discharge Voucher. Please sign the Discharge voucher and returned the same for our records.
Further as directed by the Forum the entire original medical bills (45 no.) including Discharge Summary is forwarded to our Panel Advocate so that the said Medical bills may be deposited before the forum.
It does not say which are the amounts that have been allowed and which are the amounts that have been disallowed. It is not in speaking order. In 2005 (2) KAR L.J. 375 (SC), it is ruled thus:
Reasons are links between the materials on which certain conclusions are based on the actual conclusions. They disclose how the mind is applied to the subject matter for a decision whether it is purely administrative or quasi judicial. They should reveal a rational nexus between the facts considered and conclusive reached, only in this way can opinions or decisions recorded be shown to be manifestly just and reasonable.
This applies to this case also.
8. In any event, it is seen that in Bill No. 326 dtd. 12.06.2011, OP1 has considered only Rs.1,000/- though the Bill is for Rs.2,800/- towards Ambulance and the Complainant claimed this disallowing of Rs.1,800/- which is illegal. Under the Policy, ambulance charges are restricted to only Rs.1,000/- and whole amount paid to the ambulance is not within the purview of the Policy. Hence, disallowing this amount does not amount to deficiency in service.
9. Further under Bill No. 41128 dtd. 16.08.2011, Complainant had claimed Rs.4,350/- towards purchase of Ecosprin 150MG Tab, Clopivas 75MG Tab, Cardace 2.5MG Tab, Sorbitrate 10MG Tab, Frolomet XL 25MG & Caat 20MG. OP has ticked to this, but it has not paid this amount. Hence, disallowing of this amount is nothing but deficiency in service. Why this has been declined is not answered by the OP1.
10. Under Bill No. RB2011188337 dtd. 16.08.2011, Complainant has claimed Rs.50/- towards ECG and this has been disallowed by the OP. ECG is part of the medical treatment. Hence, disallowing this amount is nothing but deficiency in service.
11. Further, under Bill No. 343 dtd. 17.06.2011, Complainant had claimed Rs.2,000/-, but the OP has allowed only Rs.1000/-. According to this Bill, Rs.2,000/- was charged towards Ambulance charges from G.S. Hospital to Jayadeva Hospital, but as per the Policy Complainant is entitled to only Rs.1,000/-. Hence, it was rightly disallowed and regarding this there is no deficiency in service.
12. Under Bill No. 4667 dtd. 17.06.2011, Complainant had paid Rs.8,600/- to G.S. Hospital at the time of discharge and it is not an advance. At the time of discharge only this amount has been paid and this has been disallowed. This is nothing but deficiency in service to this extent.
13. Complainant had paid Rs.2,000/- under Bill No. 817 dtd. 22.06.2011 towards Ambulance Charges from Chikkaballapur to Jayadeva Hospital for carrying the patient and regarding this Rs.1,000/- has been allowed on the ground that under insurance policy only Rs.1,000/- is permissible to the ambulance and not Rs.2,000/-. Hence, it was rightly disallowed and there is no deficiency in service in this regard.
14. Under Bill No. 2461 dtd. 15.07.2011, Complainant had paid Rs.810/- towards medicines that has been purchased. This has not been considered by the OP and this has been repudiated. This is nothing but deficiency in service.
15. Complainant had claimed Rs.100/- under Bill No. 37691 dtd. 15.07.2011 towards charges for (84) i.e., X-Ray and this has been disallowed by the OP without any valid reason. Taking X-Ray is also part of the medical treatment and this has been disallowed. This is nothing but deficiency in service.
16. Hence Ops for no reasons have disallowed Rs.13,910/- in all, but paid rest of the amount. Hence this amounts to deficiency in service. Hence, we hold the above points accordingly and pass the following order:
ORDER
1. Complaint is allowed in part.
2. OPs are directed to pay to the Complainant sum of Rs.13,910/- with interest @ 12% P.A. from the date of Complaint until payment within 30 days from the date of this Order.
3. Ops are also directed pay Rs.2,000/- to the Complainant as costs of this litigation.
4. OPs are directed to send the amount as ordered at (2) & (3) above to the Complainant by Demand Draft through RPAD and intimate this Forum the compliance of the Order within 45 days.
5. Send copy of the Order to the parties concerned free of cost.
6. Return extra sets to the parties concerned under Regulation 20(3) of Consumer Protection Regulations 2005.
(Dictated to the Stenographer, got it transcribed and corrected and pronounced in the open Forum on this the 18th day of August 2012)
T. NAGARAJA K.G.SHANTALA H.V.RAMACHANDRA RAO
Member Member President
SSS
