Date of Filing:13.02.2008<br /> Date of Order:18.08.2008<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> Dated: 18TH DAY OF AUGUST 2008<br /> PRESENT<br /> <br /> <br /> <br /> Sri. S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri. BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> <br /> COMPLAINT NO: 421 OF 2008<br /> <br /> <br /> K.C. Balasubramanyam,<br /> A-32, Kudremukh Colony,<br /> II Block, Koramangala,<br /> Bangalore-560 034. Complainant<br /> <br /> <br /> V/S<br /> <br /> Vijaya Simha,<br /> Sr. Divisional Manager,<br /> Divisional Office-1, III Floor,<br /> Unity Buildings Annex,<br /> 72, Mission Road, <br /> Bangalore-560 027. Opposite Party<br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> <br /> This is a complaint filed for medical claim.<br /> The brief facts of the case are that, the complainant has taken mediclaim policy for the period from 24/05/2006 to 23/05/2007. In the month of April-2007 complainant was feeling tiredness frequently and even not able to walk properly for short distance. He went to Apollo Dispensary. Doctors indicated that he is suffering from acute aneamia and requires to be admitted to hospital immediately. He went to Shamsunder Nursing Home, Basavanagudi on 05/05/2007. Doctors advised him to undergo blood check up. On 07/05/2007 he got admitted to Sham Singh Nursing Home, investigation was carried out. He was treated for Dimorphic Anemia for the period from 07/05/2007 to 10/05/2007. He has paid a sum of Rs.7,424/- to the National Insurance Company Limited and took fresh policy valid up to mid night on 23/05/2008. On 05/07/2007 complainant submitted all the details and hospital expenditure. Senior Div. Manager finally conveyed refusal of the claim amount by letter dated 16/10/2007. The complainant has claimed Rs.23,523/-. Complainant is a senior citizen. Therefore, the complainant requested kindly to award justice to him<br /> <br /> 2. Notice was issued to opposite party. Opposite party has put in appearance through advocate and filed defence version admitting that the opposite party had issued policy of insurance to the complainant and the policy was valid from 24/05/2007 to 23/05/2008. Opposite party submits that medical records reveals that the complainant has admitted to the Hospital for generalized weakness, loss of appetite for 1-2 months suffering from sever anemia for which he was treated conservatively. In view of exclusion of clause 4.10 of the policy condition the complainant is not entitled to claim compensation. There is no deficiency of service on the part of the opposite party. Therefore, the opposite party requested to dismiss the complaint.<br /> 3. Affidavit evidence of opposite party filed. Arguments are heard. Perused the documents. <br /> 4. The point for consideration is:-<br /> Whether the repudiation of medical claim by the <br /> opposite party is justified? <br /> <br /> REASONS<br /> <br /> 5. It is an admitted case of the parties that, the complainant is a senior citizen, he had taken mediclaim insurance policy by paying premium amount. The policy covered the period from 24/05/2006 to 23/05/2007. Again the complainant took fresh policy by paying Rs.7,424/- and the said policy was valid and covered the period from 24/05/2007 to 23/05/2008. The complainant was admitted to Hospital and thorough investigation was carried out. He was treated for Dimorphic Anemia for the period from 07/05/2007 to 10/5/2007. The complainant submitted claim to the opposite party with all necessary documents and bills. But unfortunately the opposite party refused to admit the claim by letter dated 16/10/2007. Therefore, the complainant was forced to approach the Forum for getting justice. The Consumer Protection Act, 1986 is a social and benevolent Act, it intends to protect better interest of the consumers. The complainant has produced certificate of Sham Singh Nursing Home. This certificate reveals that, the said Nursing Home was established in the year 1987 having a major operation theatre, minor operation theatre, labor theatre and facilities to admit all medical, surgical and maternity cases and the Hospital has also got a diagnostic facility for X-ray, ECG, Laboratory for routine examination with 10 bedded hospital. The only defence taken by the opposite party for rejecting the claim is the exclusion clause 4.10 of the policy condition. Clause 4.10 reads as under:-<br /> “Clause 4.10: Expenses incurred primarily for evaluation/diagnostic purposes not followed by active treatment during hospitalization.” <br /> <br /> The complainant was admitted to hospital and he had taken treatment in the hospital from 07/05/2007 to 10/05/2007. The defence of the opposite party is that, there was no need of hospitalization hence repudiated the claim. Whether there was need of hospitalization or not cannot be decided by opposite party. It is for the Doctor or the Medical Expert to say whether there was need of hospitalization or not. Admittedly, the complainant was admitted to hospital and he was treated for Dimorphic Anemia and a necessary treatment was given to the complainant. The complainant was discharged from hospital on 10/05/2007 and adviced to take medicine every day without fail and he was asked for review after 7 days. Again the complainant met Doctor B.N.S. Singh at Sham Singh Nursing Home and he was informed that there was improvement in his health condition and he was required to continue the medical advice for further period of 3 months. So, under these circumstances, the expenses incurred by the complainant are not only for diagnostic purposes not followed by active treatment. But in this case the complainant was admitted to the hospital and for that he has incurred expenditure. Therefore, the opposite party is not justified in rejecting the claim of the complainant. The complainant has submitted a detail memo of the expenditure towards medicine. As per the memo total amount spent by the complainant comes to Rs.20,139/- and this amount is covered by hospital bills and medical bills. Therefore, the claim submitted by the complainant is justified. The opposite party shall honour the commitment and shall pay the claim to the complainant. It is very just, fair and proper claim submitted by the complainant. Therefore, there are no justifiable and acceptable reasons to reject the claim. The complainant has claimed Rs.50,000/- as compensation for mental agony and harassment against the opposite party for not admitting the medical claim. Under the facts and circumstances of the case, it is not a case to grant any compensation. In the result, I proceed to pass the following:-<br /> <br /> ORDER<br /> <br /> 6. The complaint is allowed. The opposite party is directed to pay Rs.20,139/- to the complainant. The complainant is also entitled to interest at 12% p.a from 16th October-2007 till payment/realisation. The complainant is also entitled to Rs.1,000/- towards costs of the present proceedings from the opposite party. <br /> <br /> 7. Send the copy of this Order to both the parties free of costs immediately. <br /> <br /> 8. Pronounced in the Open Forum on this 18TH DAY OF AUGUST 2008. <br /> <br /> Order accordingly,<br /> <br /> PRESIDENT<br /> We concur the above findings. <br /> <br /> MEMBER MEMBER <br /> <br /> <br />