<br /> COMPLAINT FILED: 29.11.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> <br /> 22nd JANUARY 2009<br /> <br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT <br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI.A.MUNIYAPPA MEMBER <br /> <br /> COMPLAINT NO.2604/2008<br /> <br /> <br /> COMPLAINANT Ms.Meena Rani,D/o Mr.Mohan,Aged about 28 years,Residing at No.4, Kamala Villa, 1st Main, 7th Cross,Abbaiah Reddy Layout,Kagdasapura Extn.,C.V.Ramanagar Post,Bangalore – 560 093Advocate – Sri.S.M.ManjunathaV/s.<br /> OPPOSITE PARTIES 1. The Managing Director,United Insurance Limited Mediclaim Policy,Regd., and Head OfficeAt No.24, White’s Road,Chennai – 600 014.2. The Manager,Grievance Department,United Insurance Limited Mediclaim Policy,P.B.No.5340, 1st Floor,No.25, M.G.Road,Bangalore.Advocate – Sri.B.Pradeep<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 with respect to the hospital expenses and pay a compensation and damages 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 and her father C.Mohan took mediclaim policy from OP which was valid from 20.10.2007 to 19.10.2008. On 17.09.2007 complainant father got admitted at Trinity Hospital for prostate ailment. He was operated with regard to the said ailment and for treatment he has spent Rs.17,543-76. After the discharge he made a claim of the said amount to OP by producing all the necessary documents, but unfortunately OP did not respond. Then complainant caused legal notice on 24.10.2008, again there was no response. Hence complainant felt 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 reliefs accordingly.<br /> <br /> 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP complainant being the employee with LKP securities, obtained the mediclaim policy. Her father is not a beneficiary. OP is not aware of the fact that complainant father being operated at Trinity Hospital on 17.09.2007 and having spent Rs.17,543/- towards hospitalization. Hence OP is not obliged to settle the said claim. As there is no privity of contract between the complainant and the OP with regard to the so called mediclaim policy, question of reimbursing the said expenses does not arise. In addition to that OP never repudiated the claim of the complainant. So all the allegations of the complainant are false, frivolous and baseless. 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. It is the case of the complainant that herself and her father C.Mohan took mediclaim policy from OP. To substantiate the same the mediclaim policy card under medi care service issued by the OP are produced. The said card speaks to the fact that mediclaim policy is valid from 20.10.2007 to 19.10.2008. We are satisfied that complainant has established the fact that OP covered mediclaim insurance with respect to the complainant as well as her father C.Mohan the beneficiary. Under such circumstances the defence set out by the OP that they do not admit the said insurance coverage is unfortunate.<br /> <br /> 7. It is further contended by the complainant that her father was got admitted at Trinity hospital on 20.10.2007 and he took the treatment. Thereafter he was discharged on 23.10.2007. The discharge summary is produced. Towards the said hospitalization complainant father has spent Rs.17,543-76. The bill issued by the said hospital are produced. After the discharge complainant made a claim to the OP. Claim form copy is also produced. But unfortunately it appears OP has not considered the said claim which was submitted on 14.03.2008.<br /> <br /> 8. The evidence of the complainant appears to be very much natural, cogent and consistent. There is nothing to discard her sworn testimony. It is a quality of evidence that is more important than that of the quantity. 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. OP having kept the said claim without settling it as per the terms and conditions of the mediclaim policy for all these months definitely amounts to deficiency in service. Merely because OP has not repudiated the said claim and intimated the complainant in that regard is no ground to hold that the present complaint filed by the complainant is pre-mature. That defence of the OP also does not hold force.<br /> <br /> 9. Though complainant has produced all the necessary documents and got issued the legal notice, but still there is no proper response from the OP. The hostile attitude of the OP must have naturally caused both mental agony and financial loss to the complainant. Under such circumstances we find it is a fit case were in complainant deserves certain relief. The said policy admittedly came to be in force from 20.10.2007 and on the same day complainant father got admitted into Trinity Hospital took treatment and he was discharged after 3 days. <br /> <br /> 10. When that is so, there is an obligation lies on the OP to reimburse the said medical expenses. Refusal of the same amounts to breach of contract and agreement and deficiency in service. In the interest of justice we find it is a fit case wherein complainant deserves the reimbursement. 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. OP is directed to reimburse the medical expenses of Rs.17,544/- and pay a litigation cost of Rs.1,000/- to the complainant. 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 9% p.a on Rs.17,544/- from 14.03.2008 till realization.<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 22nd day of January 2009.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> <br /> Vln* <br /> <br /> <br />