COMPLAINT FILED: 29.11.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> 31st JANUARY 2009<br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT<br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI. A. MUNIYAPPA MEMBER <br /> <br /> COMPLAINT NO. 2605/2008<br /> <br /> <br /> COMPLAINANT Ms. Meena Rani,<br /> Daughter of Mr. Mohan,<br /> Aged about 28 years,<br /> Residing at No. 4, <br /> Kamala Villa,<br /> 1st Main, 7th Cross,<br /> Abbaiah Reddy Layout,<br /> Kagdasapura Extn.,<br /> C.V. Ramanagar Post,<br /> Bangalore – 560 093.<br /> <br /> Advocate (S.M. Manjunatha)<br /> <br /> <br /> V/s.<br /> <br /> <br /> OPPOSITE PARTIES 1. The Managing Director,<br /> United Insurance Limited Mediclaim Policy,<br /> Regd., and Head Office at<br /> No.24, White’s Road,<br /> Chennai – 600 014.<br /> <br /> <br /> 2. The Manager,<br /> Grievance Department,<br /> United Insurance Limited Mediclaim Policy,<br /> P.B. No. 5340, 1st Floor,<br /> No. 25, M.G. Road,<br /> Bangalore.<br /> <br /> Advocate for OP.2 (B. Pradeep)<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 medi claim with regard to the expenses incurred by the complainant and pay a compensation of Rs.2,00,000/- 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 took a medi claim policy of her own and on behalf of her mother Smt. Kamala Rani from OP while working with LKP Securities Limited. OP accepted the proposal and issued the policy which was in force from 20.10.2007 to 19.10.2008. In the month of March 2008 complainant’s mother Kamala Rani experienced some problem with her eyes. She was taken to Navashakthi Nethralaya. On examination it was noticed that there is a cataract ailment on both right and left eye. She was operated on 13.03.2008 with respect to right eye and on 03.04.2008 she again underwent operation with respect to left eye. Complainant has incurred a hospital expenses of Rs.47,800/-. After the discharge of her mother she made claim to OP by producing all the necessary documents including the discharge summary, hospital bills. Though OP kept the said matter pending for more than 8 months neither it settled nor it repudiated the claim. Hence complainant got issued the legal notice on 24.10.2008. Again there was no response. Thus complainant felt the deficiency in service on the part of the OP. For no fault of her, she is made to suffer both mental agony and financial loss. Under the circumstances she 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 complainant has failed to mention the policy number and membership number. Actually there is no privitiy of contract between the OP and the mother of the complainant Smt. Kamala Rani. In order to settle the claim complainant must produce some documents to show that she has actually paid the hospital bills. Money receipts with stamp attached are to be produced. But no such documents are produced. OP kept pending the said claim for want of proper records and documents. At no point of time OP repudiated the said claim, hence the present complaint is pre-mature. There is no deficiency in service on the part of the OP. As such OP is not liable to pay either compensation or the medical expenses as claimed. 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. 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 Affirmative<br /> Point No.2:- Affirmative<br /> Point No.3:- As per final Order.<br /> <br /> <br /> R E A S O N S<br /> <br /> 6. It is the contention of the complainant that while working with LKP Securities Limited she took the medi claim policy from the OP for herself and for the benefit of her mother Smt. Kamala Rani. OP accepted their proposal and issued the policy, allotted them the No. 03100607993A for the complainant 03100607993X for the mother of the complainant which was in force from 20.10.2007 to 19.10.2008. To substantiate the said contention complainant has produced the medi claim policy identity card issued by the OP. There is nothing to discard the sworn testimony of the complainant. The mother of the complainant Kamala Rani is the beneficiary under the said policy. As against this unimpeachable evidence of the complainant, the defence set out by the OP is very strange.<br /> <br /> 7. OP has taken up the contention that the policy number, membership number mentioned in the complaint is not admitted. When OP has issued the policy and issued the card referred to above it is too much on the part of the OP to set up such a defence. This kind of defence leads us to draw an inference that it is a defence only for a defence sake, just to shirk their responsibility and obligation. Further OP says that to settle the claim they are required to verify the hospital bills, money receipts with revenue stamps. This contention also appears to be a mere eye wash. Complainant has produced medi claim form accompanied with the hospital records including the discharge summary and the expenses incurred for the treatment, in patient hospitalization bills, OT consumables list and the prescription as well as the amount being paid to the said hospital towards the operations conducted and also sent good number of e-mails. What more communication and documents OP requires, we fail to understand.<br /> <br /> 8. As already observed by us, complainant has substantially established the fact that during the course of the insurance coverage her mother the medi claim policy holder underwent cataract operation on 13.03.2008 and 03.04.2008 of both her eyes and thereby she spent nearly Rs.47,800/- and there is a proof of payment of the said amount by the complainant. There is nothing to discard the sworn testimony of the complainant and the contents of the undisputed documents. OP having failed to settle the said claim for more than 8 months on flimsy reasons amounts to deficiency in service. <br /> <br /> 9. Merely because OP has not repudiated the said claim in writing is no ground to hold that the present complaint is pre-mature. OP is expected to settle the claim in either of the way within a reasonable time, but to the reasons best known to the OP it took its own sweat time and went on dogging the settlement of the claim. The approach of the OP does not appears to be fair and honest. People go for medi claim policy in a good faith that at the time of hour of need Insurance Company will come to their help and assistance. But if OP causes unreasonable delay to settle the claim on flimsy reasons and grounds, then the people may loose faith in the said medi claim insurance scheme itself.<br /> <br /> 10. Viewed from any angle, we are satisfied that there is a proof of deficiency in service on the part of the OP. For no fault of the complainant and her mother they are forced to face both mental agony and financial loss. Under such circumstances they are entitled for the relief claimed. With these reasons 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 allowed in part. OP is directed to settle the claim for Rs.47,800/- and pay the same to the complainant along with litigation cost of Rs.1,000/- within 4 weeks from the date of communication of this order. Failing in which OP is directed to pay interest at the rate of 12% p.a. on Rs.47,800/- from the date of legal notice (24.10.2008) till realization along with a 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 31st day of January 2009.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> p.n.g. <br />