<br /> COMPLAINT FILED: 31.10.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> <br /> 19th DECEMBER 2008<br /> <br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT <br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI.A.MUNIYAPPA MEMBER <br /> <br /> COMPLAINT NO.2341/2008<br /> <br /> <br /> COMPLAINANT Sri.S.N.Subramanya,(Senior Citizen)118 “Lakshmikrupa”,5th Main Road,I.T.I Layout, Benson Town,Bangalore – 560046.V/s.<br /> OPPOSITE PARTY Senior Divisional Manager,United India Insurance Company Ltd.,24 Classic Building,Richmond Road,Bangalore – 560025.Advocate – Sri.B.Pradeep<br /> <br /> O R D E R<br /> <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 medical claim and pay a compensation in all to the tune of Rs.10,188/-. <br /> <br /> The brief averments, as could be seen from the contents of the complaint, are as under:<br /> <br /> Complainant availed the mediclaim policy from the OP from the year 2001 and it has been renewed every now and then without any break. The latest policy is in force from 01.11.2008 to 31.10.2009. As the complainant felt uneasiness he approached Wockhardt hospital, Cunningham Road and undergone coronary artery by pass grafting surgery on 26.06.2006 and was discharged on 02.07.2006. Thereafter he took treatment on 01.10.2008. He has incurred an expenses of Rs.3,187/-, he made the claim to OP to reimburse it. Though he patiently waited for more than one or two months OP did not oblige to settle the claim. For no fault of his, he is made to suffer both mental agony and financial loss. Under the circumstances he felt deficiency in service on the part of the OP. Accordingly he is advised to file this complaint and sought for the reliefs.<br /> <br /> 2. On appearance, OP filed the version mainly contending that before claiming the reimbursement of the expenses complainant is required to give a notice to the third party Administrator within 7 days from the date of hospitalization. Complainant has not complied clause 6.1 of the terms and conditions of the policy, he has become the defaulter. Hence he can’t allege the deficiency in service on the part of the OP. For the first time complainant approached the OP on 10.10.2008. He took the treatment as an outpatient. So the claim of the complainant is against the clause 2.3 of the terms and conditions of the policy. On that score also complainant is not entitled for the relief claimed. Actually OP has not repudiated the claim of the complainant. For want of better particulars and proper notice it is kept pending. Complaint is pre-mature. There is no deficiency in service on the part of the OP. 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. 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 <br /> the OP?<br /> <br /> Point No. 2 :- If so, whether the complainant is <br /> entitled for the relief’s 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 Affirmative<br /> Point No.2:- Affirmative in part<br /> Point No.3:- As per final Order.<br /> <br /> <br /> R E A S O N S<br /> <br /> 6. The fact that complainant had availed the mediclaim policy from OP since the year 2001 and renewed the same without any break right up to 31.10.2009 is not at dispute. Now it is the contention of the complainant that due to some chest pain he approached Wockhardt hospital and undergone coronary artery by pass grafting surgery on 26.06.2006 and he was discharged on 02.07.2006. Again on 01.10.2008 he took treatment at the same Hospital. In that regard he has incurred an expenses of Rs.3,187/-. After the discharge he contacted the OP to settle the claim by sending an E-mail. Copy of the E-mail is produced. Though complainant patiently waited for few months it was not settled. Thus complainant felt deficiency in service on the part of the OP.<br /> <br /> 7. As against this it is contended by the OP that complainant is required to give notice to the third party Administrator within 7 days from the date of hospitalization, he has not done it. It is further contended that complainant took the treatment as an outpatient. Hence his claim is hit by clause 2.3 of the terms and conditions of the policy. The fact that OP covered the insurance is not at dispute. When complainant made a claim that itself can be taken as a notice for settling his medical bills. OP wants to take some flimsy defence to avoid their obligation and responsibility.<br /> 8. It is also not at dispute that complainant undergone coronary artery by pass grafting surgery. Whether he took the said treatment as an inpatient or out patient it matters little. Unfortunately OP has taken up the defence that treatment taken is not covered under the policy terms and conditions. In another breath it admits that so far so good they have not settled the claim of the complainant. That means to say it is kept pending. What is the reason for not settling the said mediclaim demand is not known. The hostile attitude of the OP amounts to deficiency in service.<br /> <br /> 9. Complainant took the mediclaim policy with a fond hope that OP will come to his assistance and aid in case of necessity. But unfortunately OP on some untenable defence invoking some provisions of terms and conditions of the policy kept pending the claim which is not fair. It is against to the good faith reposed. We have also taken note of the terms and conditions and the so-called clauses referred to by the OP.<br /> <br /> 10. As already discussed by us in the above said paras non settling of the claim well with in the reasonable time amounts to deficiency in service. Complainant for no fault of his is made to suffer both mental agony and financial loss. Under such circumstances he is entitled for the relief claimed to some extent. With these reasons we answer point Nos.1 & 2 accordingly and proceed to pass the following: <br /> <br /> O R D E R<br /> <br /> The complaint is allowed in part. OP is directed to settle the claim for Rs.3,187/- and pay a litigation cost of Rs.500/- to the complainant. This order is to be complied within four weeks from the date of its communication.<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 19th day of December 2008.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> <br /> <br /> <br /> Vln* <br /> <br />