BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.47/2017

DATED ON THIS THE 8^th December 2017

Present:  1) Sri. H.M.Shivakumara Swamy

B.A., LLB., - PRESIDENT  

    2) Smt. M.V.Bharathi                   

                                   B.Sc., LLB., -  MEMBER

    3) Sri. Devakumar.M.C.                

                                            B.E., LLB., PGDCLP,    - MEMBER

Sri M.C.DEVAKUMAR,

Member

1.     The complainant has filed the complaint under section 12 of the C.P.Act 1986, against the ops alleging seeking a direction to pay Rs.16,073/- along with interest at 18% p.a. and Rs.1,00,000/- compensation for the deficiency in service with such other reliefs.
2.     The complainant holding a Janatha Mediclaim Policy (Hospitalization benefit policy) from opposite party No.2, undergone “cataract surgery” at Sushrutha Eye Hospital at Mysore on 17.05.2016.  A claim for a sum of Rs.26,873/- was made under the policy, by submitting all the relevant documents on 10.06.2016.  Opposite party No.1 settled  the claim for Rs.10,500/- only.  Vide letter dated 19.07.2016 the complainant demanded for payment of balance amount of Rs.16,373/-, but the opposite party No.1, deposited just Rs.300/- to the complainant’s Bank account.  The hospital demanded for balance payment.  A legal notice caused on 16.12.2016, calling upon to pay the balance amount was in vain.  Hence, complainant alleging deficiency in service and seeking reliefs.
3.     The opposite party No.2 filed a common version denying the allegations as false.  The issuance of policy was admitted and the same was subject to terms and conditions.
4.     The opposite party No.1 was the service provider under the policy governed by the IRDA, who gives necessary instructions in arriving at a calculation of amount to be paid and make the payment directly to the hospitals.  Accordingly, a sum of Rs.10,800/- have been paid as against the claim of Rs.24,500/-.  A reply was given narrating the details of payment in response to the legal notice.  As per the policy clause only, the admissible amount for cataract operation i.e. Rs.10,800/- have been paid.  Hence, there is no negligence and deficiency in service and prays for dismissal of the complaint.
5.     In order to establish the facts, both parties filed affidavit in lieu of evidence and written arguments.  Heard the counsels and by perusing the material on record, matter posted for orders.
6.     The points arose for our consideration are:-

1. Whether the complainant established the negligence and deficiency in service on the part of opposite parties, for not making the balance hospital expenses and thereby he is entitled for the relief sought?
2. To What order?

7.    Our findings on the aforesaid points are as follows:

Point No.1 :- In the negative.

Point No.2 :- As per final order for the following

:: R E A S O N S ::

8.    Point No.1:- The complainant obtained a Janatha Mediclaim policy (hospitalisation benefit policy) for a sum of Rs.50,000/- on 30.08.2015.  The complainant underwent “cataract surgery” at Sushrutha Eye Hospital at Mysore on 17.05.2016 and incurred an hospital expenses of Rs.26,873/-.  He claimed the same by submitting all the documents. 
9.    Opposite party No.1 paid Rs.10,500/- only to the hospital.  The complainant repeatedly demanded for balance amount of Rs.16,373/-. But, opposite party No.1 deposited Rs.300/- to the complainant’s account. Later the complainant issued a legal notice, calling upon to pay the remaining amount, but in vain.  As such, alleged the deficiency in service and sought for the reliefs.
10. The opposite party No.2 contended that, the Janatha mediclaim policy was subject to terms and conditions and the clause 2.10 clearly specifies the payment for specific disease such as for “cataract operation a sum of Rs.10,800/- only.  As such, the claim has been settled after verifying the claims with the documents submitted.  The legal notice sent was suitably replied on 16.12.2016, in detail.  The opposite party No.2 contended that, there is no negligence and deficiency in service on their part as such, the complainant is not entitled to receive any reliefs as claimed.  Hence, prayed for dismissal of the complaint with costs.
11. Admittedly, the complainant obtained a Janatha Mediclaim policy from opposite party No.2, since 30.08.2006 and continued until 29.08.2016, and remitted the premium amount regularly.  The said policy benefits are subject to the terms and conditions as laid down.  The complainant being policy holder, undergone cataract operation and the hospital expenses of Rs.24,500/- was estimated.  The opposite party No.1 had paid Rs.10,800/- by scrutinising the medical records as against the claim of Rs.26,873/-. The demand for balance amount towards hospitalization was rightly rejected based on the policy clause No.2.10 – schedule of payment for specified diseases.  The policy document established the admissible amount to be paid for cataract operation.  Thereby, the contention of opposite party No.1 is justified and the complainant is not entitled for any benefit as sought.  Accordingly, point No.1 is answered in the negative.
12. Point No.2:- In view of the observations made in point No.1 above, we proceed to pass the following

:: O R D E R ::

1. The complaint is hereby dismissed.
2. Give the copies of this order to the parties, as per Rules.

(Dictated to the Stenographer transcribed, typed by her, transcript corrected by us and then pronounced in open court on this the 8^th December 2017)