BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, MYSORE-570023

CONSUMER COMPLAINT NO.68/2021

DATED ON THIS THE 14^th December 2022

Present:      1) Sri. B.Narayanappa

M.A., LL.B., - PRESIDENT  

                     2) Smt.Lalitha.M.K.,

M.A., B.A.L., LL.B., - MEMBER  

                        3) Sri Maruthi Vaddar,

                                                B.A., LLB (Special)  - MEMBER

Sri MARUTHI VADDAR,

MEMBER

1.         This complaint has been brought under Section 35 of the C.P.Act, 2019 by the complainant Smt.Bharathi Hegde.S. resident of Vijayanagara, Mysuru alleging deficiency of service against the opposite party M/s Medi Assist of National Insurance Company, Bannerghatta Road, Bangalore directing the opposite party to pay compensation by way of damage to the tune of Rs.4,37,000/- with interest for deficiency of service from 3^rd March 2020 till the disposal of the complaint and pass such other order as deems fit in the facts and circumstances of the case in the interest of justice and equity.        
2. The brief facts of the complaint in a nutshell is as here under:-

It is alleged in the complaint that while working in Bank of Baroda, the complainant has obtained the policy bearing No.5001002819P112575620 having a member ID 5049424276.The husband of the complainant at the first time obtained treatment from Apollo Hospital, Mysuru from 10.02.2020 to 14.02.2020 for severe pneumonia, again on 15.02.2020 to 20.02.2020 for septic arthritis.On both occasions the complainant spent Rs.4,37,398/-.

It is further alleged that on 03.03.2020 the complainant has preferred a claim petition before the opponent and sought relief of the amount spent on the treatment and on 12.06.2020 the complainant sent the additional documents as called for by opposite party on 21.07.2020, 01.08.2020, 25.09.2020 and 20.10.2020.But, on 14.10.2020 opposite party communicated to the complainant through E-mail that the claim of the complainant was repudiated for the reason that the ailment of the husband is related to old age and obesity and hence the claim is rejected, though the doctors who have treated the husband, certified that the said ailments are not related to either obesity or age related and though the certificates were also conveyed to the opposite party, later, refused to honour the claim which amounted to deficiency of service.Hence, this complaint.

3. After the registration of the complaint, notice was issued to the opposite party and in pursuance of the notice sent by this Commission, opposite party did not appeared and hence the opposite party placed exparte.
4. The complainant has filed her affidavit by way of examination in chief and the same was taken as P.W.1 and got produced certain documents as Ex.P.1 to Ex.P.10.   
5. Heard the arguments of the complainant and the complainant has also filed written arguments.
6. The points that would arise for our consideration are as here under:-  

1. Whether the complainant proves the alleged deficiency in service on the part of the opposite party and thereby she is entitled to the reliefs as sought for?
2.  What order?

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

      Point No.1 :- Partly in the affirmative.

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

:: R E A S O N S ::

8.       Point No.1:- To demonstrate the averments of the complaint, the complainant has been examined as P.W.1 by filing her chief affidavit towards her chief examination and got marked documents as Ex.P.1 to Ex.P.10.  The complainant has reiterated the averments of the complaint in her chief affidavit.  Ex.P.1 is the claim form dated 02.03.2020 contain 3 sheets.  Ex.P.2 is the bill dated 20.02.2020.  Ex.P.3 is the medical bill dated 14.02.2020. Ex.P.4 is the order of repudiation of claim by opposite party dated 14.10.2020.  Ex.P.5 and 6 are the doctors certificates dated 20.10.2020.  Ex.P.7 is the discharge summary contains 8 pages. Ex.P.8 is the discharge summary contains 7 pages.  Ex.P.9 is the deposit receipt dated 17.02.2020.  Ex.P.10 is the deposit receipt dated 17.02.2020.  The complainant has produced two more documents, one is postal cover and another one is health cards issued by opposite party.  After the testimony of the complainant, the complainant has submitted her oral as well as written arguments.  After carefully perusing the complaint averments, it is noticed that during her employment in the then Vijaya Bank, the complainant has obtained a group insurance policy with other employees of her bank from opposite party vide policy No.5001002819P112575620 having a member ID 5049424276.  It is further case of the complainant that she admitted her husband for the first time to BGS Apollo Hospital, Mysuru from 10.02.2020 to 14.02.2020 for treatment to severe pneumonia and again admitted on 15.02.2020 to 20.02.2020 for septic arthritis and spent nearly Rs.4,37,398/-.
9. But on 03.03.2020 the complainant has preferred a claim to opposite party and submitted the required documents as demanded by opposite party, but the opposite party sent a E-mail to the complainant that her claim is repudiated for the reasons that the ailment of the husband is related to old age and obesity and hence rejected. Though the notice has been sent to the opposite party by this Commission after the registration of the complaint, but the opposite party did not appeared and not filed its version.  The conduct of the opposite party in abstaining  from the proceedings shows that the opposite party acknowledges the claim of the complainant.  The opposite party contended that the said ailments of the husband of the complainant is related to old age and obesity.  But, the opposite party failed to produce required documents in support of its claim.  Mere pleading without proof is fatal to reason put forth by the opposite party though the complainant has produced relevant doctor certificates as per Ex.P.5 and 6 wherein it is clearly opined that the pneumonia is infected in nature which is unrelated to obesities and there was focus of infection in left knee joint which is not related to age, degenerative changes or obesity.  Such being the case, the opposite party has not produced any cogent evidence to falsify the certificates submitted by the complainant.  The opposite party is also failed to adduce rebuttal evidence to the evidence given by the complainant.  Hence, the complainant has proved her case against the opposite party for the alleged deficiency in service within the meaning of Section 2(11) of C.P.Act, 2019, the repudiation of the claim of the complainant by opposite party is improper and unjustifiable.  The opposite party is answerable to the claim of the complainant.  Hence, we have answered this point No.1 in partly affirmative.
10. Point No.2:- For the aforesaid reasons, we proceed to pass the following

:: ORDER ::

1. The complaint of the complainant is allowed in part.
2. The opposite party is hereby directed to pay Rs.4,37,000/- compensation along with 6% interest p.a. from the date of repudiation till its payment.
3. The opposite party is further directed to pay Rs.10,000/- towards deficiency of service caused to the complainant and Rs.5,000/- towards the cost of the present proceedings within one month from the date of the order, failing which Rs.10,000/- + Rs.5,000/- will carry 10% interest p.a. till its payment.
4. The complainant is at liberty to take necessary action, under Section 72 of C.P.Act for non-compliance the order.
5. Furnish the copy of order to both parties at free of cost.

(Dictated to the Stenographer transcribed, typed by her, corrected by us and then pronounced in open Commission on this the 14^th December, 2022)