COMPLAINT FILED: 29.12.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> 26th FEBRUARY 2009<br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT<br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI. A. MUNIYAPPA MEMBER <br /> <br /> COMPLAINT NO. 2848/2008<br /> <br /> <br /> COMPLAINANT Sri. Musrif Ashok,<br /> Aged about 51 years,<br /> S/o. Raghavendra Rao Musriff,<br /> No. 80, B1 (SFS) B-Sector, <br /> Bharani Nilaya,<br /> 4th ‘B’ Cross, <br /> New Town Yelahanka,<br /> Bangalore – 64.<br /> <br /> <br /> Advocate (Mahantappa)<br /> <br /> <br /> V/s.<br /> <br /> <br /> OPPOSITE PARTIES 1. The Divisional Manager,<br /> United India Insurance <br /> Company Limited,<br /> No. 1114/63, Thakur Complex,<br /> 1st Main, S.C. Road,<br /> Yeshwanthapur,<br /> Bangalore – 22.<br /> <br /> <br /> Advocate (Janardhan Reddy)<br /> <br /> <br /> 2. The Managing Director,<br /> Vipul Med-Corp. Private Ltd.,<br /> No. 154, Mallige Complex,<br /> KHB Colony, 5th Block,<br /> Koramangala,<br /> Bangalore – 95.<br /> <br /> <br /> O R D E R<br /> <br /> This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction to the Opposite Party (herein after called as O.P) to settle the claim for Rs.69,807/- and pay a compensation of Rs.25,000/- and for such other reliefs on an allegations of deficiency in service. <br /> <br /> The brief averments, as could be seen from the contents of the complaint, are as under:<br /> Complainant had obtained medical insurance policy from the OP. During the subsistence of the said policy coverage his wife Smt. Chanda Musrif was hospitalized for treatment at K.K. Hospital, Yelahanka from 26.08.2008 to 30.08.2008 and thereafter she was admitted in Columbia Asia Medical Centre, Hebbal, Bangalore from 07.09.2008 to 12.09.2008 for the treatment of hysterectomy. Complainant has paid all the medical bills, which come to the tune of Rs.69,865/-. After the discharge complainant submitted the claim to OP, but to his utter shock and surprise OP settled the claim only for Rs.12,126/- and Rs.25,000/- as against Rs.69,865/-. The repeated requests and demands made by the complainant to reimburse all the medical expenses, went in futile. Hence he got issued the legal notice on 11.12.2008 to OP. Again there was no proper response. Complainant felt the deficiency in service on the part of the OP. Under the circumstances he is advised to file this complaint and sought for the relief accordingly.<br /> <br /> 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP it has issued gold policy which was valid from 29.08.2008 to 28.08.2009. With respect to the claim of the complainant for having taken treatment by spending Rs.12,226/-, it was honoured as per the terms and conditions of the policy, but complainant refused to sign the discharge voucher and accept the same. With regard to the treatment of hysterectomy, complainant is bound by the terms and conditions of the gold policy. OP has covered the risk only to the extent of 20% of the sum assured. Under such circumstances they calculated the reimbursement to the tune of Rs.25,000/- as against the sum assured Rs.1,25,000/- and kept ready the bill, again complainant refused to accept the same. So no fault lies with the OP. There is no deficiency in service. The claim of the complainant to the tune of Rs.69,865/- is highly imaginary and exorbitant. The complaint is devoid of merits. Among these grounds, OP prayed for the dismissal of the complaint.<br /> <br /> 3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced some documents. OP has also filed the affidavit evidence and produced the documents. Then the arguments were heard.<br /> <br /> 4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under:<br /> <br /> Point No. 1 :- Whether the complainant has proved <br /> the deficiency in service on the part of the OP?<br /> <br /> Point No. 2 :- If so, whether the complainant is <br /> entitled for the reliefs now claimed?<br /> <br /> Point No. 3 :- To what Order?<br /> <br /> <br /> 5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on:<br /> <br /> Point No.1:- In Negative<br /> Point No.2:- Negative<br /> Point No.3:- As per final Order.<br /> <br /> <br /> R E A S O N S<br /> <br /> 6. It is contended by the complainant that he took the medical insurance policy from OP. For which period he took the same is not mentioned. He has also not mentioned about OP having covered the insurance under gold policy which was valid from 29.08.2008 to 28.08.2009. So complainant has suppressed certain material facts which are well within his knowledge. Of course the fact that the complainant wife took treatment at K.K. Hospital, Yelahanka, Bangalore is not seriously disputed by the OP. According to OP as per the terms and conditions of the policy they have settled the claim for Rs.12,126/- after deducting Rs.100/- towards registration charges and kept ready the discharge voucher, intimated the complainant. The copy of the discharge voucher dated 01.11.2008 is produced, but complainant refused to accept the same. Under such circumstances no fault lies with the OP.<br /> <br /> 7. It is further contended by the complainant that his wife underwent hysterectomy at Columbia Asia Medical Centre and he incurred the expenses of Rs.57,517/-. Of course OP has not disputed this claim also. But according to the terms and conditions of gold policy issued by the OP clause 1.2 (C) risk OP covered is only 20% of the sum assured that too if the claim is within first two years and the sum assured is Rs.1,25,000/-. Hence OP settled the claim for Rs.25,000/- and kept ready the discharge voucher on 18.11.2008 willing to pay the said amount to the complainant. But again complainant has not responded for the same. We have gone through the policy conditions, actually the hospitalization expenses under the said gold policy condition limit fixed is Rs.23,750/-. With all that OP is ready to pay Rs.25,000/-. <br /> <br /> 8. The contents of the documents produced by the OP are not disputed by the complainant. They abundantly speaks to the fact that towards the hysterectomy OP liability is 20% of the sum assured or maximum Rs.50,000/-. When OP has kept ready the claim inconsonance with the terms and conditions of the policy, that act of the OP cannot be termed as deficiency in service. The approach of the complainant does not appears to be fair and honest. When OP is ready to settle the claim in terms of the policy conditions, what made the complainant to refuse the said offer is not known. <br /> <br /> 9. Under such circumstances we find the claim of the complainant for Rs.69,807/- appears to be arbitrary. Even till today the complainant can accept the said offer made by the OP, no such prejudice will be caused to the complainant. For these reasons we find the complaint is devoid of merits. There is no proof of deficiency in service. Hence the complainant is not entitled for the relief claimed. The option is still open to the complainant. With these observations we answer point nos.1 and 2 accordingly and proceed to pass the following: <br /> <br /> O R D E R<br /> <br /> The complaint is dismissed. In view of the nature of dispute no order as to costs.<br /> <br /> (Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 26th day of February 2009.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> p.n.g. <br /> <br /> <br /> <br />