BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE
Dated this the 17th March 2017
PRESENT
SRI VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SRI T.C. RAJASHEKAR : HON’BLE MEMBER
ORDERS IN
C.C.No.284/2014
(Admitted on 28.07.2014)
Mr. Robert Mascarenhas,
Age 53 years,
S/o Late Basil Mascarenhas,
Residing at D.No.21.137/1,
Silvas Gate, Kotimaura House,
Kulshekar, Mangalore 575005.
….. COMPLAINANT
(Advocate for the Complainant: Sri JRN)
VERSUS
The Senior Branch Manager,
The Oriental Insurance Company Ltd,
3rd Floor, Krishna Prasad Building, above Pabbas,
M.B. Road, Lalbagh,
Mangalore 575003.
….......OPPOSITE PARTY
(Advocate for the Opposite Party: Sri AKK)
ORDER DELIVERED BY HON’BLE PRESIDENT
SRI. VISHWESHWARA BHAT D:
I. The above complaint filed under Section 12 of the Consumer Protection Act by the complainant against opposite party alleging deficiency in service claiming certain reliefs.
The brief facts of the case are as under:
The complainant claims that he obtained Universal Health Insurance Policy from opposite party for the period from 02.07.2013 to 01.07.2014 covering for Hospitalization, expenses for medical/surgical treatment at any Nursing Home/Hospital in India as an in-patient as mentioned in the policy for Coronary Artery disease towards admitted and treat at A.J. Hospital & Research Centre, Kuntikana, Mangalore from 08.04.2014 and 09.04.2014 with the bill of Rs.7,991/. When the bills were furnished with opposite party approved the claim only for a sum of Rs.3,523/ thought complainant is entitled for Rs.7,991/ under the policy. Hence seeks the relief claimed in the complaint.
II. Opposite party in the written version admitted the issue of the policy coverage of Rs.30,000/ to complainant as floater sum insured receive of the bills is also admitted. On terms and conditions of the policy total limit for room and boarding expenses is Rs.150/ per day and maximum CCU charges is Rs.300/ and while processing the claim there are no receipts from the complainant not produced for payment of bill of their professional charges. Hence by approving for Rs.3,523/ only intimated the complainant. Hence seeks dismissal of the complaint.
2. In support of the above complainant Mr. Robert Mascarenhas field affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked Ex.C1 to C7 as detailed in the annexure here below. On behalf of the opposite party Mr. Raghu Naik (RW1) Assistant Manager, also filed affidavit evidence and answered the interrogatories served on him and produced documents got marked Ex.R1 to R6 as detailed in the annexure here below.
III. In view of the above said facts, the points for consideration in the case are:
- Whether the Complainant is a consumer and the dispute between the parties?
- If so, whether the Complainant is entitled for any of the reliefs claimed?
- What order?
The learned counsels for both sides filed nots of arguments. We have considered entire case filed on record including evidence tendered by the party and notes arguments of the parties. Our findings on the points are as under follows
Point No. (i) : Affirmative
Point No. (ii): Affirmative
Point No. (iii): As per the final order
REASONS
IV. POINTS No. (i): In this the relationship of consumer and the service provider is admit. Only the part of the claim made on behalf of complainant by opposite party is admitted. Hence there is dispute between the parties in honouring the entire bill as contemplated under section 2 (1) (e) of the C P Act. Hence we answer point No.1 in the affirmative.
POINTS No. (ii): The ground urged by opposite party for sanction only portion of the bill was limitations in the policy. Ex.R1 is the original policy issued by opposite party to complainant show the total sum insured as Rs.30,000/ As seen from this policy though it mentions the insurance under this policy is subject to conditions, clauses, warranties, endorsements no such terms and conditions except endorsement of the reverse side is produced there is no any condition even as we can make out opposite party did not produce any terms and conditions of the policy in the course of evidence. Hence the claim of opposite party on this count as to the term and conditions claimed in their written version in the absence of any evidence on record cannot be accepted.
2. It is seen the ground urged in the objections is the limitations of the room charged CCU charges and not produced the receipts of the doctors. However the original bills copy Ex.R2 of which is produced in the case by complainant shows CCU charges per day is 2,500 and the doctors charges Rs.200/ per day of the Specialist and of Cardiologists at Rs.350/ per day totalling Rs.400/ and Rs.700/ respectively is mentioned totalling the claim of Rs.7,991/ mentioned in the final bill. It is not the case of opposite party that the amount was paid by complainant to the doctor directly but it is included in the final bill issued by the hospital to complainant. Hence opposite party cannot insist for a separate bill from the doctors. Hence the claim of opposite party that when the terms and conditions of the policy are not in dispute before the Forum the deduction and failure of honouring the entire bill to the complainant in our view is unjustified and amounts to deficiency in servicer. Hence we answer point No.2 in the affirmative.
POINTS No. (iii): Complaint is to be allowed with cost hence opposite party shall be directed to pay Rs.7,991/ to complainant with interest at 8% from the date of legal notice 28.5.2014 till the date of payment. Opposite party shall also be directed to pay Rs.5,000/ as compensation towards mental agony and Rs.2,000/ towards cost. Wherefore the following
ORDER
The complaint is allowed with cost. Opposite party is directed to pay Rs.7,991/ (Rupees Seven thousand Nine hundred Ninety One only) with interest at the rate of 8% per annum to complainant from the date of legal notice i.e. 28.5.2014 till the date of payment.
2. Opposite party shall also pay Rs.5,000/ (Rupees Five thousand only) to complainant as compensation and another Rs.2,000/ (Rupees Two thousand only) towards cost.
3. The above amounts shall be paid within 30 days from the date of receipt of copy of this order.
Copy of this order as per statutory requirements, be forwarded to the parties free of cost and file shall be consigned to record room.
(Page No.1 to 6 directly typed by steno on the computer system to the dictation of President revised and pronounced in the open court on this the 17th March 2017)
MEMBER PRESIDENT
(T.C. RAJASHEKAR) (VISHWESHWARA BHAT D)
D.K. District Consumer Forum D.K. District Consumer Forum
Additional Bench, Mangalore Additional Bench, Mangalore
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 Mr. Robert Mascarenhas
Documents marked on behalf of the Complainant:
Ex.C1: 17.06.2013: Copy of the policy issued by the opposite Party bearing No.422203/47/2014/100
Ex.C2: 09.04.2014: Copy of Discharge Summary
Ex.C3: 08.04.2014: Copy of Diagnostic Report
Ex.C4: 09.04.2014: Copy of Medical Bills
Ex.C5: 29.04.2014: Letter issued by the Opposite party
Ex.C6: 28.05.2014: Copy of Lawyers notice
Ex.C7: 06.06.2014: Acknowledgement card having received Document No.6 above
Witnesses examined on behalf of the Opposite Parties:
RW1 Mr. Raghu Naik, Assistant Manager,
Documents marked on behalf of the Opposite Parties:
Ex.R1: Policy copy
Ex.R2: Discharge summary
Ex.R3: Original medical bills (6)
Ex.R4: Letter dated 29.4.2014 of opposite party
Ex.R5: Letter dated 18.06.2014 of opposite party
Ex.R6: Claim computation sheet
Dated: 17.03.2017 PRESIDENT
