IN THE DISTRICT CONSUMERS’ DISPUTES REDRESSAL FORUM AT MYSORE<br /> <br /> PRESENT: 1. Shri.A.T.Munnoli<br /> B.A., L.L.B (Spl.) - President <br /> <br /> 2. Smt.Y.V.Uma Shenoi<br /> M.Sc., B.Ed., - Member<br /> 3. Shri. Shivakumar.J.<br /> B.A., L.L.B., - Member<br /> <br /> <br /> CC 148/09 DATED 23.09.2009<br /> ORDER<br /> <br /> Complainant C.R. Nagaraja S/o Rangaraju. C, # 140, ‘A’ Block, 16th cross, 2nd main, J.P. Nagar, 1st stage, Mysore.<br /> <br /> (Sri. S. Shankara. Advocate)<br /> <br /> Vs. <br /> Opposite Party 1. The Branch Manager, The New India Assurance Company Ltd., No.2733, 3rd cross, R.P. Road, Opposite K.E.B. Nanjangud-571301.<br /> 2. The Paramount Health Services Pvt. Ltd., No.10/1, First floor, Next to institute of Agriculture Technologies, Queen Road, Bangalore-560052.<br /> <br /> (Sri. J.S.K. Advocate for first O.P, 2nd O.P. is exparte)<br /> Nature of complaint : Deficiency in service<br /> Date of filing of complaint : 17.04.2009<br /> Date of appearance of O.P. : 21.05.2009<br /> Date of order : 23.09.2009<br /> Duration of Proceeding : 4 Months 2 days<br /> <br /> <br /> PRESIDENT <br /> <br /> <br /> <br /> MEMBER<br /> <br /> <br /> MEMBER<br /> <br /> <br /> Sri. A.T.Munnoli,<br /> President<br /> <br /> 1. Complainant has filed the complaint under Section 12 of the Consumer Protection Act against the opposite parties seeking a direction to pay a sum of Rs.4,540/- as mediclaim with interest at the rate of 18% p.a. and further Rs.10,000/- compensation and Rs.5,000/- cost of the proceedings.<br /> <br /> 2. In the complaint it is alleged that, the complainant is mediclaim policy holder bearing No.671005/34/07/20/00000115 issued by the opposite parties valid from 27.07.2008 to 26.07.2008. The policy covers claim of father of the complainant. During validity period, father of the complainant was admitted in the hospital for ill health from 14.07.2008 to 21.07.2008, at Davanagere. Complainant spent Rs.5,434.84 for the treatment. The complainant made two representations to opposite parties with relevant documents. The opposite parties rejected the claim on unreasonable clauses without verifying the documents. According to the terms of the policy, the complainant is entitled to receive the claim amount. After legal notice the opposite parties sent claim discharge voucher. Claim of the complainant is Rs. 5,434.84, but the opposite parties have reduced and settled for a sum of Rs.894 only. Remaining amount has not been paid by the opposite parties amounting to deficiency in service. Hence, it is prayed to allow the complaint.<br /> <br /> 3. The first opposite party in the version contended that, the second opposite party is a third party administrator. Under the Regulations, there is tie up with it. It is stated the second opposite party after scrutinizing the documents submitted by the complainant has rejected the claim on the ground that the patient was admitted for investigation purpose and no line of management. Also it is contended that this opposite party has no power to settle the claim. Hence, it is prayed to dismiss the complaint.<br /> <br /> 4. Initially the complainant had made the first opposite party only as a party and after the first opposite party took a contention that the second opposite party is a necessary party, that has been impleaded. In spite of receipt of the notice, the second opposite party has remained exparte.<br /> <br /> 5. To prove the facts alleged in the complaint, the complainant has filed his affidavit and produced certain documents. For the first opposite party the Divisional Manager has filed his affidavit, wherein the facts with reference to the version are stated. <br /> <br /> 6. We have heard the arguments and perused the material on record. <br /> <br /> 7. Now, the points for our consideration are as under.<br /> <br /> 1. Whether the complainant has proved any deficiency in service on the party of the opposite parties and that he is entitled to the relief claimed?<br /> 2. What order?<br /> <br /> 8. Our findings are as under:-<br /> Point no.1 : Affirmative<br /> Point no.2 : As per the order.<br /> <br /> REASONS<br /> <br /> 9. Point no. 1:- Without repeating the facts mentioned earlier, the main dispute raised by the opposite party in repudiating the claim of the complainant is that, father of the complainant was admitted in the hospital only for investigation purpose. Thus the learned counsel for the first opposite party submitted that, father of the complainant was not suffering with any disease and was admitted only for investigation purpose and for which the complainant cannot make any claim.<br /> <br /> 10. Advocate for the complainant with reference to the documents on record pointed out that at the outset it is not that, father of the complainant was admitted in the hospital only for investigation, but in fact the complainant had to purchase medicine and diagnostic test charges, as well as consultant’s fees. To substantiate this fact, copies of various documents are placed on record, That fact is stated by the complainant in his affidavit. The said payment made by the complainant as per the bills or receipts produced and relied upon, there is no dispute.<br /> <br /> 11. As noted above, only contention of the opposite party is that father of the complainant was admitted for investigation purpose. But the fact remains that, father of the complainant was admitted in the hospital and during the relevant period certain medicines were purchased, for father of the complainant as per the prescription of the doctor. Further, from the discharge sheet it can be seen that, father of the complainant was admitted with the history of giddiness and headache associated with omitting, pain and neck region etc.,. Advocate for the complainant referred to clause 2.4 of the mediclaim policy which provided expenses reimbursable under the policy in respect of medicines and drugs, laboratory/diagnostic tests and other medical expenses relating to the treatment etc.,. Hence we are of the considered opinion that rejection of the claim of the complainant by the opposite parties is unreasonable. There are no justified grounds to reject the said claim. Consequently there is deficiency in the service on the part of the opposite parties. <br /> <br /> 12. Accordingly we answer the point No.1 in affirmative. <br /> <br /> 13. Point No. 2:- From the discussions made above and conclusion arrived at, we pass the following order: <br /> <br /> ORDER<br /> <br /> 1. The Complaint is partly allowed.<br /> 2. Both the opposite parties jointly and severally are liable to pay a sum of Rs.4,540/- to the complainant with interest at the rate of 10% p.a. from the date of the order till realization. The opposite parties shall pay the amount within a month from the date of the order.<br /> 3. Further, both the opposite parties jointly and severally shall pay a sum of Rs.3,000/- to the complainant towards mental agony and inconvenience caused. So also a sum of Rs.1,000/- towards cost of the proceedings. This amount also shall be paid within a month from the date of the order.<br /> 4. Give a copy of this order to each party according to Rules.<br /> (Dictated to the Stenographer, transcribed by her, transcript revised by us and then pronounced in the open Forum on this the day 23rd Sept 2009)<br /> <br /> <br /> <br /> (A.T.Munnoli) <br /> President <br /> <br /> <br /> (Y.V.Uma Shenoi)<br /> Member<br /> <br /> <br /> (Shivakumar. J)<br /> Member<br /> <br />