BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.206/2018

DATED ON THIS THE 13^th June, 2019

      Present:  1) Sri. C.V.Maragoor

B.Com., L.L.M., - PRESIDENT   

                     2) Sri. Devakumar.M.C.           

                                        B.E., LLB., PGDCLP   - MEMBER

Sri C.V.MARAGOOR,

President

1.          This complaint filed by Sharath Narashimhan, resident of Mysuru to direct the opponent Medi Assist Insurance TPA Pvt. Ltd., Bengaluru to pay Rs.15,000/- remaining sum payable, Rs.50,000/- as compensation towards deficiency in service and Rs.25,000/- towards cost of this proceedings. 
2.           The complainant is working as Quality Manager in Wipro Limited at Mysuru and has taken medical insurance policy for a base sum of Rs.2,00,000/- which is default and further he has made additional top up of Rs.2,00,000/- in all total coverage for Rs.4,00,000/- which includes maternity charges upto Rs.50,000/-.  The complainant’s wife had admitted to Brundhavan Hospital, Mysuru for delivery on 19.03.2018 and she gave birth to male child on 20.03.2018 and she was discharged on 23.03.2018.  Total bill of the hospital was Rs.81,215/- and after deducting discount a sum of Rs.7,215/- the complainant has paid Rs.74,000/-.  Out of this Rs.35,000/- has been paid by the opponent and remaining of Rs.39,000/- borne by the complainant.
3.           The complainant has requested the opponent to pay remaining amount of Rs.15,000/- in terms of the policy condition.  The opponent did not respond to the notice dated 05.05.2018 hence, this complaint.
4.           The opponent in spite of personal service of the notice was remained absent in this proceedings hence, it is proceeded exparte. 
5.           The complainant to prove his case filed affidavit in lieu of evidence and marked Exhibits P.1 to P.11.    
6.           Heard the arguments advanced by the learned counsel for the complainant and the points that would arise for determination are as under:-   

1. Whether the complainant proves that the act of opposite party in repudiating the part of the claim amount amounts to deficiency in service?
2. Is complainant entitled to the relief sought for?
3. What order?

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

Point No.1 :- In the affirmative;

Point No.2 :- In the partly affirmative;

Point No.3 :- As per final order for the below

:: R E A S O N S ::

8.         Point Nos.1 to 3:- The learned counsel for the complainant urged that though there is a clause in the mediclaim insurance policy for payment of Rs.50,000/- towards maternity expenses, the opponent has evaded to pay the full amount.  The complainant marked Ex.P.1 insurance policy issued in favour of him dated 15.11.2017.  The wife of complainant was admitted in Brundhavan Hospital during insurance coverage period i.e. on 19.03.2018 and gave birth to male child on 20.03.2018.   The hospital has issued bill for Rs.74,000/-.  The complainant marked Ex.P.6 legal notice dated 05.05.2018 to  pay the remaining amount of Rs.15,000/-.  The opponent has not given reply to the said notice.
9.        Ex.P.1 medical insurance policy reveals that towards maternity expenses the company has agreed to pay Rs.50,000/- for normal delivery for top up plan.  According to the policy, the complainant is entitled for maternity benefits a sum of Rs.50,000/- but the opponent has not complied with the policy benefits by paying Rs.50,000/- to the complainant though the hospital has billed for Rs.74,000/-.  The act of opposite party repudiating part of the policy benefits amounts to deficiency in service.  The complainant has not produced any material show that he has suffered pain and suffering for not paying part of the policy benefit.  Pain and suffering cannot be measured however on the part of deficiency in service by opponent the complainant is entitled for Rs.10,000/- as compensation and Rs.5,000/- towards cost of the proceedings. In the result, we  proceed to pass the following:-

:: O R D E R ::

1. The complaint filed by Sharath Narasimhan is partly allowed directing the opposite party to pay a sum of Rs.15,000/- with interest at the rate of 10% p.a. from 20.03.2018 till its payment.
2. In addition to that the opposite party is directed to pay Rs.10,000/- as compensation and Rs.5,000/- towards costs of this litigation to the complainant within two months from the date of order.   Otherwise, it carries interest at the rate of 10% p.a. from the date of filing the complaint till payment.
3. Furnish the copy of the order to the complainant and opposite party at free of cost.

(Dictated to the Stenographer transcribed, typed by her, transcript corrected by us and then pronounced in open court on this the 13^th June, 2019)