Complaint filed on: 27.08.2012

                                                      Disposed on: 28.01.2017

BEFORE THE IV ADDL DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM, BENGALURU

 1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027       

CC.No.1726/2012

DATED THIS THE 28^th JANUARY OF 2017

PRESENT

SRI.H.Y.VASANTHKUMAR, PRESIDENT

SRI.D.SURESH, MEMBER

SMT.N.R.ROOPA, MEMBER

Complainants: -                            

1. Prasad S.T.

s/o Srinivas T

Aged about 36 years

R/at No.28, 7^th cross,

Subbanna garden,

Vijayanagar

Bengaluru-560040

2. Smt.Uma G

w/o Prasad S.T

aged about 29 years

R/at No.28, 7^th cross,

Subbanna garden,

Vijayanagar

Bengaluru-560040

         By Adv. Sri.R.Manjunatha

V/s

Opposite parties:-    

1. The Oriental Insurance co. ltd. Oriental House,

P.B.No.7037, A-25/27, ASAF ALI Road,

New Delhi-110002

     By Adv.Sri.V.Prathima

2. Medi Assist India TPA

Pvt Ltd, 49,

Shilpa Vidya Building

1^st Main, Sarakki Industrial layout,

3^rd phase, J.P.Nagar, Bengaluru-560078

    Opposite party No.2

    -Ex-parte

ORDER

Under section 14 of consumer protection Act. 1986.

SRI.H.Y.VASANTHKUMAR, PRESIDENT 

            The Complainants/husband & wife have been alleging the deficiency in service in repudiating their insurance claim amount and thereby have claimed the total compensation amount of Rs.25,773/- with interest and litigation charges from the Opposite parties.

          2. The case of the Complainants in brief is that they were the beneficiary of a “group mediclaim and personal accident insurance policy” standing in the name of the first of them, because of his employment at Bengaluru stock exchange. The Complainant No.2 because of her ill health, on medical advice of Dr.K.Subramanya admitted got to Apoorva diagnostic centre at Indiranagar on 31.03.2012 and underwent operation for removal of Hemorrhoids Plus Fissure In Ano and got discharged on 01.04.2012. Thereafter also she took treatments as outpatient. They spent total cost of Rs.25,590/- as supported by hospital records Ex-A2 to A8 and took medicines out side at Rs.183.37. Both of them submitted the claim from with all necessary documents on 02.04.2012 as per Ex-A1 and their claim was repudiated as per Ex-A9 on the ground that they had taken treatment in a non-registered hospital which has less than 15 beds. Such grounds are made with malafide intention to delay their claim during the enforcibility of the policy. Hence, this complaint is filed.

          3. Opposite party No.2 is placed ex-parte. Opposite party No.1 has questioned the maintainability of this complaint denying the allegations made against him contending that the Complainants violated the terms & conditions of the policy. The violated term 2.1 of the policy as per Ex-B1, which says that the hospital where they want to take treatment should have 15+ beds in metropolitan city. The violation of the policy terms made them to get repudiation letter which is issued rightly in accordance with the law and terms & conditions. Hence complaint becomes liable to be dismissed.  

          4. The Complainants and their witness Ramachandra as PW1 to PW3 and the official of the Opposite party No.1as DW1 filed their affidavit evidences. The Complainants have relied on Ex-A1 to Ex-A9 documents. The Opposite party No.1 has relied on Ex-B1 document. Written arguments were filed by both sides. Arguments were heard.  Perused the records.

          5. The consumer disputes that arise for consideration are as follows:

1. Whether the Complainants establish the deficiency in service in repudiating their medical insurance claim against the Opposite parties ?
2. To what order the parties are entitled ?

6. Answers to the above consumer disputes are as under:

1) Negative

2) As per final order – for the following      

REASONS

          7. Consumer Dispute No.1: The undisputed facts reveal that the Complainant No.1 is the husband of Complainant No.2 and he was the beneficiary of Ex-B1/“group mediclaim and personal accident insurance policy” of the Opposite parties, which was in force in 2012. The said policy had covered the insurance to his wife the Complainant No.2. The Complainant No.2 on medical advice underwent operation on 31.03.2012 at “Apoorva diagnostic centre at Indiranagar” and got discharged on 01.04.2012 as supported by medical records Ex-A2 to A8. When the insurance claim form was filed with required documents as per Ex-A1 by the Complainants on 02.04.2012, it was repudiated by the Opposite party No.1 vide Ex-A9 letter on the ground that the term no.2.1 of Ex-B1/policy was violated by them as their hospital was having below 15 beds.

          8. In Ex-A9 repudiation letter dtd.20.06.12, the Opposite parties have mentioned that the Apoorva hospital/diagnostic centre does not conform to the minimum requirements of clause 2.1 of Ex-B1 policy, as it is unregistered 10 bedded hospital and was block listed/‘D’ listed hospital. It is also further stated that its right is reserved to repudiate on any other grounds also, contending that their act of repudiation does not amount to deficiency in their service.

          9. The contractual terms of Ex-B1 about the definition clause 2 of the hospital/nursing home reads as here under:

          2. Definitions:

          2.1: “HOSPITAL/NURSING HOME’ means by institution in India established for indoor care and treatment of sickness and injuries and which either

a) Is duly licensed and registered as a Hospital and Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner

                               OR

b) In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognized in locality as Hospital/Nursing home and should comply with minimum criteria as under

i) It should have at least 15 in-patient medical beds in case of Metro cities, A class cities & B class cities or 10 in-patient medical beds in case of ‘C class’ cities. Classification of cities shall be as per Govt. of India Notifications issued in this respect from time to time.

ii) Fully equipped and engaged in providing Medical and Surgical facilities along with Diagnostic facilities i.e. Pathological test & X-ray, E.C.G etc. for the care and treatment of injured or sick persons as in-patient.

iii) Fully equipped operation theatre of its own, wherever surgical operations are carried out

iv) Fully qualified nursing staff under its employment round the clock.

v) Fully qualified Doctor(s) should be physical in-charge round the clock.

          10. It also appears that the Complainants have not issued the prior notice to the Opposite parties before filing of this complaint and it shows that they were aware about the conditions of Ex-B1 and also about the fate of that block listed hospital.

          11. PW3, the Chief Manager of Apoorva Diagnostic centre though has stated about the treatment given to the Complainant No.2 has not stated about his right to accept the patients of insurance policy holders and has not stated how his hospital becomes entitled to be recognized by the Opposite parties insurance co.,

          12. The contractual obligations of the Ex-B1 policy shows that the Complainants being the policy holders ought to have taken care about the compliance of the terms mentioned therein, but they failed to select the hospital as defined under clause 2. Hence they do not become competent to file the claim form and the act of the Opposite parties to rely on the definition “hospital” in terms of policy cannot be considered as deficiency in their service. Hence the Complainants failed to establish the Consumer Dispute No.1 and accordingly it is answered in the negative.

          13. Consumer Dispute No.2: In view of the finding of Consumer Dispute No.1 the Complainants deserve to get the following:

ORDER

          The Complaint of the Complainants is here by dismissed. No order as to costs.

          Supply free copy of this order to both the parties. 

          (Dictated to the Stenographer, got it transcribed, typed by her/him and corrected by me, then pronounced in the Open Forum on 28^th day of January 2017).

Documents marked on behalf of Complainants:

Documents produced on behalf of Opposite party