BEFORE THE SOUTH MUMBAI  DISTRICT  CONSUMER DISPUTES REDRESSAL FORUM,

Puravatha Bhavan, 1^st Floor, General Nagesh Marg, Near Mahatma Gandhi Hospital, Opp. M.D. College, Parel, Mumbai – 400 012.

                                                                 O.No.

Complaint No.SMF/MUM/CC/2014/271

                                                  Date of filing :   20/11/2014

                                                Date of Order:   29/11/2017

Mrs. Kamladevi K. Damani,

E/1311, Ryal Samrat, S.V. Road,

Goregaon (West),

Mumbai – 400 104.                                             ….. Complainant.    

          V/s.

1.The New India Assurance Co.Ltd.,

   Through its Divisional Manager,

   Office at Jain Towers,

  10^th & 11^th Floor, 17, Mathew Road,

  Opp. Roxy Cinema, Opera House,

  Mumbai – 400 007.

2. Medi Care TPA Services Pvt.Ltd.,

   Through its Manager,

  Office at 6, Bishop Lefroy Road,

  Kolkata – 700 020.                                            ….. Opposite Party

                    Coram:

     Shri. G.K. Rathod              :   Hon’ble President

Shri. S.R. Sanap              :   Hon’ble Member

Appearance  :     

 For Complainant        –  Adv. Smt.   Sharmista D. Gandhi 

For Opponent No. 1  -   Adv. Smt. Shilpa Veerkar    

Opponent No. 2        -   Ex-parte

                   // JUDGMENT //

PER SHRI. G.K. RATHOD – HON’BLE  PRESIDENT

                 The  Complainant has filed the complaint against the Opponent No. 1 who is Insurance Company and the Opponent No.2 is its TPA Third Party claim settlement administrator. As the Opponent No.1 wrongfully and illegally rejected the claim of the Complainant in respect of the treatment taken by the Complainant who is covered under the mediclaim policy which covers the risk and benefit of medical treatment of the Complainant and therefore, there is deficiency in service and unfair trade practice on the part of the Opponent. 

                   The Complainant is a subscriber of the mediclaim policy since the year 2001 and paying premium regularly.  The present policy is valid and subsisting during the treatment taken by the Complainant and the valid period of the policy is 15/10/2013 to 14/10/2014 for the sum assured Rs. 1,50,000/- and cumulative bonus amounting to  Rs. 30,000/- marked ‘A’.  The Complainant was admitted for treatment on 18/7/2014 and discharged on 7/8/2014 document is at Exh. ‘B’. As per the treatment for period of 21 days, from 18/7/2014 to 7/8/2014, followed by the physiotherapy and regular consultation and observation of the doctors.  It is further contended that for taking above said treatment, the Complainant has paid Rs. 1,25,000/- plus other charges, she has produced the bill at Exh. ‘C’.  After discharge from the hospital, the Complainant has submitted her claim before the Opponent No. 1 claiming Rs. 1,32,380/- alongwith all medical papers and documents,  it is at Exh. ‘D’  dtd. 5/9/2012.  But the Complainant was surprised to receive rejection letter dtd, 16/9/2014 from the Opponent No. 2 stating that the claim of the Complainant was repudiated and rejected, the letter is at Exh. ‘E’. Then the Complainant immediately contacted to the Opponent No.  2 for reconsideration of rejected claim.  But the Complainant had not got any response from the Opponent.  It is further submitted that at the instance of the Government of India, the Board of Directors of the Opposite Party, adopted Citizens Charter on 4/9/1997 declaring therein their commitment to the insuring citizen time frame, within which various services like insurance, documents and settlement of the various types of the claims shall be settled either way.  The Complainant will be relied upon Citizen Charter adopted by the Opponent.  The Complainant’s claim is of Rs. 1,32,380/- is below Rs. 20,00,000/- and main office of the Opponent is in the jurisdiction of this Forum, the Complainant is a policy holder, therefore, this complaint is filed under the Consumer Protection Act.  The relief claimed  for Rs. 1,32,380/- with interest @18% p.a. from the date of treatment taken by the  Complainant and/or from the date of repudiation letter issued by the Opponent and/or from the date of filing of present complaint,  Rs.25,000/- by way of compensation and Rs. 25,000/- by way of professional charges and fees incurred by the Complainant for engaging services of the Advocate.       To support his contention, the Complainant has filed documents alongwith the list, mediclaim policy and premium receipt, terms and conditions of the mediclaim policy and SBF Patient Discharge Summary, Shop and Establishment License of SBF, bills and payment receipts for treatment, claim form, bills and vouchers, repudiation letter dtd. 16/9/2014, brochure of SBF Health Care Centre and also judgment copies,  on which the Complainant is relied.

(2)               After receipt of the notice to  the Opponent Nos. 1 and 2, the Opponent  No. 2 remained absent hence proceeded exparte against the Opponent No. 2 and the Opponent No. 1 filed written version on 26/3/2015 in which it is contended that complaint is false the Opponent No. 1 has rightly repudiated the claim of the Complainant and the Complainant’s case is liable for dismissed.  It is further contended that the complainant is the holder of the policy issued by the Opponent No. 1 and the Complainant had  made claim for reimbursement of her alleged treatment of Osteoarthritis known as SPMF Therapy filed from SBF Health Care Centre.  From the document it appears that the treatment taken by the Complainant is  OPD treatment which is not payable as per the insurance norms and terms and condition of the policy and therefore, the claim was repudiated as the policy covers only hospitalization expenses means admission in hospital for a minimum period of 24 hours in patient Care consecutive hours or except for specified procedures of treatment.  The Opponent has filed documents, such as, claim repudiation letter dtd. 16/9/2014, letter dtd. 12/8/2014, discharge summary by SBF Healthcare & Research Centre Pvt.Ltd. terms and conditions of the policy.

(3)               From the above facts, the following points arose for my consideration

REASONING :

(4)               From the contents of the complaint, affidavit evidence, written arguments, documents placed on record by the parties and written version, it is admitted fact that the policy is valid during the period the Complainant had taken the treatment and the sum assured is Rs. 1,50,000/-  the Complainant has filed his claim of Rs. 1,32,380/- , the treatment was taken by the Complainant and also filed the discharge summary of Mrs. Kamla Devi Damani and patient was admitted for 8 hours tentatively.   As per terms and conditions clause 2.16.1  hospitalization means admission in a hospital for a minimum period of 24 hours in patient care consecutive hours except for a specified procedures / treatments.  In the present case, the Complainant has taken a treatment from hospital for 21 days consecutively from 18/7/2014 to 7/8/2014 and therefore, in the exception for the rule, she is entitled for claim and therefore, we found substance in the complaint and therefore, we can say that the Opponent No. 1 wrongfully repudiated the claim of the Complainant and it appears that there is a deficiency and  unfair trade practice on the part of the Opponent No. 1 and therefore, the Complainant is entitled for Rs. 1,32,380/- with interest @ 9% p.a.  from the date 16/9/2014 on which the Complainant has received a repudiation letter from the Opponent that her claim is repudiated till its realization.  The Complainant is also entitled for Rs. 5,000/- towards mental agony and cost of Rs. 2,000/-.   No order as against the Opponent No.2.      

(5)               With the aforesaid discussion, we proceed to pass the following order:-

//O R D E R//

1. The complaint is partly allowed.
2. The Opponent No. 1 shall pay to the Complainant  the sum of Rs. 1,32,380/- alongwith interest @ 9% p.a.  from the date 16/9/2014 on which the Complainant has received a repudiation letter  till its realization.
3. The Opponent No. 1 shall pay to the Complainant the sum of Rs. 5,000/- towards mental agony and  sum of Rs. 2,000/- towards costs.  
4. The Opponent No. 1  to comply the aforesaid order within a  period of (30) days from the date of receipt of this order.
5. No order as against the Opponent Nos. 2.
6. Certified copy of this order be supplied to both the parties free of costs.       

          sd/-xxx                                                    sd/-xxx/-

        (Shri. S.R. Sanap)                                 (Shri.G.K. Rathod)

 Hon’ble  Member                                    Hon’ble President

Note:-  As the pleadings, affidavit, documents of the parties are in English, the order in the proceeding is passed for the better knowledge of the parties in English.

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