BEFORE THE MANDYA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANDYA PRESENT: 1. SIDDEGOWDA, B.Sc., LLB., President, 2. M.N.MANOHARA, B.A., LLB., Member, 3. A.P.MAHADEVAMMA, B.Sc., LLB., Member, ORDER Complaint No.MDF/C.C.No.1/2009 Order dated this the 31st day of March 2009 COMPLAINANT/S Sri.S.B.Krishna S/o Bettaiah, R/at Sathanur Village, Kasaba Hobli, Mandya Taluk. (By Sri.S.L.Shankar., Advocate) -Vs- OPPOSITE PARTY/S The Branch Manager, United India Insurance Co., Ltd., No.1119/B, M.C.Road, Mandya. (By Sri.B.A.Vijay., Advocate) Date of complaint 02.01.2009 Date of service of notice to Opposite party 19.01.2009 Date of order 31.03.2009 Total Period 2 Months 12 Days Result The complaint is allowed, directing the Opposite party to refund Rs.4,095/- with cost of Rs.750/- within 4 weeks, failing which the Opposite party is liable to pay interest at 9% p.a. from the date of complaint till realization. Sri.Siddegowda, President 1. This complaint is filed under section 12 of the Consumer Protection Act 1986 for refund of medical claim of Rs.4,095/- with notice charges of Rs.1,000/- with interest. 2. The case of the complainant is that the complainant had taken family health insurance policy from the Opposite party Company, which is valid from 13.12.2007 to 12.12.2008. The sum insured is Rs.50,000/- for each of the family members and the Opposite party has issued a card No.DLR-U1-0000-HO-16765-D. Further, the complainant for the problem of motion, met Dr.Nandeesh of J.S.S. Hospital, Mysore and as per the advice of the above said doctor, Colonoscopy was made and the complainant was admitted as inpatient on 11.08.2008 and discharged on 12.08.2008 in inpatient No.74780. The complainant has spent totally Rs.4,095/-. After discharge from the Hospital, the complainant claimed the expenditure in the prescribed form on 04.09.2008 along with original receipts. But the Opposite party did not respond in any manner. Even though, the petitioner has issued a legal notice through RPAD on 22.11.2008 and though served the Opposite party did not settle the claim. Therefore, the Opposite party has committed deficiency in service. Hence, the present complaint is filed. 3. The Opposite party has filed version, admitting that the complainant has taken family health insurance policy from the Opposite party and the complainant has paid the premium and Opposite party has issued a card. The averment that the complainant on the advice of Dr.Nandeesh admitted to J.S.S. Hospital and spent Rs.4,095/- are all false. It is not admitted, that complainant preferred the claim to Opposite party and the Opposite party did not respond. There is a tie up arrangement between the Opposite party and TTK Health Care Services in respect of settlement of the mediclaims and all the claims are to be settled by the TTK Services and not the Opposite party. The claim form with some medical records were submitted by the complainant on 04.09.2008 to the said TTK and on verification, the TTK called for some other requirements by their letter dated 15.09.2008. But the complainant has not complied with the said letter and hence settlement was not made and consequently no repudiation has been made by the said TTK Services and hence, attribution of the deficiency in service on the part of Opposite party would not arise. Therefore, the complaint is not maintainable and the complaint is liable to be dismissed. 4. During trial, the complainant is examined and produced the copies of the medical record Ex.C.2 & Ex.C.1 is the legal notice. The Opposite party has not filed any affidavit and no evidence is adduced. 5. We have heard both sides. 6. Now the points that arise for our considerations are:- 1. Whether the Opposite party has committed deficiency in service in not settling the claim? 2. Whether the complainant is entitled to the mediclaim of Rs.4,095/- with notice charges of Rs.1,000/- and interest? 7. Our findings and reasons are as here under:- 8. The undisputed facts are that the complainant has obtained Family Health Insurance Policy from the Opposite party valid from 13.12.2007 to 12.12.2008 and the Opposite party has issued the health card. The complainant has produced Ex.C.2 the discharge summary issued by the J.S.S. Hospital, Mysore with medical records and bills. It shows that the hospital charges Rs.3,795/- for ward charge, service charge, endoscopy, visiting charges and profession charges Dr.Nandeesh and the complainant has purchased medicine of Rs.224.99/- paise, it is not disputed. The complainant has produced the endoscopy report and discharge certificate Ex.C.2 proves that he was admitted on 11.08.2008 and discharged on 12.08.2008. According to the complainant, he submitted to claim to the Opposite party and not to the TTK. Admittedly, the claim is not settled. As per the version of the Opposite party, the complainant submitted claim form with some medical bills to TTK Services which sought for particulars and complainant did not fulfill to the requirements and hence, the TTK Services has not settled the claim. Though there is a tie up between the Opposite party Insurance Company and TTK Services, when the complainant submitted a claim form, the Opposite party should have consulted with a TTK Services. The Opposite party has not produced any document to prove that actually claim petition was made to the TTK Services by the complainant and TTK Services sent letter to the complainant calling for more particulars. The Opposite party has not filed any affidavit in support of the contention. Further, the complainant got issued a legal notice Ex.C.1 and served on Opposite party as per postal acknowledgement Ex.C.1(a), but Opposite party has not cared to reply, nor settled the claim. Therefore, it clearly amounts to deficiency in service. In view of the medical bills, totally the complainant has spent Rs.4,095/- and the Opposite party is liable to refund the same. The complainant has sought for legal notice of Rs.1,000/-, but the legal notice charges is very exhogerative for a claim of Rs.4,095/-. But considering the facts of the case, we proceed to pass the following order; ORDER The complaint is allowed, directing the Opposite party to refund Rs.4,095/- with cost of Rs.750/- within 4 weeks, failing which the Opposite party is liable to pay interest at 9% p.a. from the date of complaint till realization. (Dictated to the Stenographer, transcribed, corrected and then pronounced in the open Forum this the 31st day of March 2009). (PRESIDENT) (MEMBER) (MEMBER)
