<br /> COMPLAINT FILED: 30.12.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> <br /> 17th MARCH 2009<br /> <br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT <br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI.A.MUNIYAPPA MEMBER <br /> <br /> COMPLAINT NO.2858/2008<br /> <br /> <br /> COMPLAINANTS 1. Mr.T.J.Kuriakose,S/o T.K.Joseph,Aged about 58 years.2.Mrs.Annie Kuriakose,W/o Mr.T.J.Kuriakose,Aged about 52 years.Both are residing at No.301,MARIA KRIPA,12/2, Richards Town,Bangalore – 560 084.Advocate – Sri.B.SudeendranathV/s.<br /> OPPOSITE PARTIES 1. M/s.United India Insurance Company Ltd.,Divisional Office – III,No.24, Classic Building,I Floor, Richmond Road,Bangalore – 560 025.2. M/s.Medi Assist India Pvt. Ltd.,No.49, Shilpa Vidya,3rd Floor, Sarakki Indl. Layout1st Main Road, JP Nagar 3rd Stage,Bangalore – 560 078Advocate – Sri.B.S.Raghu Prasad<br /> <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 insurance claim for Rs.12,294/- along with interest and pay a compensation of Rs.1,00,000/- 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 /> <br /> Complainant availed the services of OP.1 who covered the insurance for Rs.3,00,000/-, it was valid from 01.02.2007 to 31.01.2008. OP.2 acted as third party administrator. On 13.09.2007 complainant No.2 the wife of complainant No.1 who is the beneficiary under the policy felt giddiness and severe omitting. Hence she immediately went to Santhosh Hospital for treatment, she was administered medicine and advised for MRI scanning. Complainant No.2 felt relief hence returned back to home. But again on 15.09.2007 the said problem aggravated. She actually collapsed in the toilet, immediately she was taken to St. Johns Medical College Hospital for treatment. The doctors who examined her subjected her to various diagnostic tests in order to come to the conclusion with regard to the real suffering and ailment. She was admitted in the hospital for observation and treatment, ultimately she was discharged on 18.09.2007. On the perusal of the tests report complaint of giddiness and neck pain radiating to left upper limb is due to vertigo. Hence they gave her the treatment for the said ailment. She was also subjected for MRI. Complainant spent nearly Rs.12,294/- towards the said treatment. After the discharge they made claim to OP but unfortunately OP repudiated the said claim on the ground that the expenses incurred by the complainant is primarily for investigation and not for the treatment of any existing disease. Under exclusion clause 4.10 OP is not liable to pay the investigation charges hence they repudiated the said claim. Complainant felt that the said repudiation is unjust and improper. She caused the notice to the OP. Again there was no response. Thus she felt deficiency in service. Accordingly she is advised to file this complaint and sought for the reliefs.<br /> <br /> 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP complainant was admitted to hospital for only clinical tests and after the said tests it was diagnosed that she suffering from Vertigo. The exclusion clause of the policy at the clause 4.10 it is specifically made clear that the investigation expenses are not covered under the policy, hence they repudiated the claim. According to OP second complainant did not under go any treatment for any kind of disease and ailment but she was admitted only for investigation purpose. All the routine tests are done. On thorough verification of the discharge summary and other hospital records and after due application of the mind OP repudiated the claim. There is no deficiency in service on the part of the OP. 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 complainants have Proved <br /> the deficiency in service on the part of <br /> the OP?<br /> <br /> Point No. 2 :- If so, whether the complainants are <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 /> R E A S O N S<br /> <br /> 6. At the outset it is not at dispute that the complainant No.1 being the Can Card holder took the Can Mediclaim Insurance Policy from OP.1 covering himself and wife complainant No.2. Risk covered is for Rs.3,00,000/-. The said policy was in force from 01.02.2007 to 31.01.2008. OP.2 is a third party administrator. Of course OP has not disputed the fact of issuance of the mediclaim insurance. Now it is the grievance of the complainant that on 13.09.2007 complainant No.2 felt giddiness and severe omitting, hence she went to Santhosh Hospital. She was administered medicine and advised for MRI Scanning. As she felt relief she returned home. If complainant had any ulterior motive they would have got admitted in the hospital but they are not greedy to make claim of unwanted expenses. The fairness of the complainant has to be appreciated.<br /> <br /> 7. It is further contended by the complainant that on 15.09.2007 again complainant No.2 felt severe omitting and giddiness. Actually she collapsed in the toilet hence she was taken to St. Johns Medical College Hospital for treatment. The hospital records are produced. In order to know the real aliment and the disease which has resulted in the sudden collapse of the complainant No.2 she was subjected to various diagnostic tests and examinations including that of MRI Scan. It is a matter of prudence that when unconscious person who suddenly collapsed in the toilet was brought to the hospital to know the real cause the patient will be certainly subjected to various tests and examinations. Unless it is done, no such treatment can be given because what is the kind of disease and ailment patient is suffering is unknown. Under such circumstances we don’t find force in the allegations of the OP that the expenses incurred by the complainant are only towards investigation and not for the treatment to the disease which she was suffering.<br /> <br /> 8. On going through the test report and investigation and MRI ultimately it was diagnosed that complainant No.2 is suffering from Vertigo which is the real cause for giddiness and neck pain radiating to left upper limb. Accordingly the medicine was administered. Hence for this simple reason we say that the complainant took the treatment for ailment and incurred the expenses of Rs.12,294/-. The supporting hospital records, documents and bills are produced including the insurance policy. With all that unfortunately OP repudiated the claim of the complainant on a technical reason and grounds.<br /> <br /> 9. We are of the view that the said repudiation is unjust and improper without due application of the mind. Naturally complainant for no fault of her is made to suffer both mental agony and financial loss. The history discloses that she was treated in the past for cervical spondylosis?. So she did suffer from certain ailment. Accordingly she was treated and discharged.<br /> <br /> 10. We are satisfied that the complainant is able to prove the deficiency in service on the part of the OP. Hence she is entitled for the relief. The evidence of the complainant appears to be very much natural, cogent and consistent. There is nothing to discard her sworn testimony. As against this unimpeachable evidence of the complainant the defence set out by the OP appears to be defence for defence sake just to shirk their responsibility and obligation. The approach of the OP does not appear to be fair. The hostile attitude of the OP must have naturally caused both mental agony and financial loss to the complainants. Under such circumstances they are entitled for the relief claimed. Accordingly we answer point Nos.1 & 2 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 reimburse the medical expenses of Rs.12,294/- and pay a litigation cost of Rs.1,000/-. This order is to be complied within four weeks from the date of its communication. Failing in which complainant is entitled to claim interest at the rate of 12% p.a on Rs.12,294/- from the date of repudiation till realization and also entitled for litigation cost.<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 17th day of March 2009.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> Vln* <br /> <br /> <br />