The Manager, Medi Assist India TPA Pvt Ltd., The Divisional Manager, The New India Assurance Co., Ltd.,
...........Respondent(s)
BEFORE:
Complainant(s)/Appellant(s):
OppositeParty/Respondent(s):
OppositeParty/Respondent(s):
OppositeParty/Respondent(s):
ORDER
Date of Filing:09.12.2009 Date of Order: 30.10.2010 2 BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SESHADRIPURAM BANGALORE-20 Dated: 30TH DAY OF OCTOBER 2010 PRESENT Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President. Smt. D. LEELAVATHI, M.A.LL.B, Member. Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member. COMPLAINT NO: 2898 OF 2009 Jeerige Bangarappa S/o. Late J. Halappa R/at MF 22/1, B.D.A. Flats SFHS Layout, BTM II Stage Bangalore 76 Complainant V/S 1. The Manager Medi Assist India TPA Pvt. Ltd. No. 49, 3rd Floor, 1st Main Road Sarakki Industrial Layout 3rd Phase, J.P. Nagar, Bangalore 78 2. The Divisional Manager The New India Assurance Co. Ltd. No. 346, 2nd Floor, Manandi Court 27th Cross, 3rd Block, Jayanagar Bangalore 11 Opposite Parties ORDER By the President Sri S.S. Nagarale This is a complaint filed under section 12 of the Consumer Protection Act. The facts of the case are that complainant has taken a mediclaim insurance policy. He took policy in the month of June 2005 and same is renewed every year. Last premium for the policy is paid on 12.07.2009. The complainant has paid premium amount of Rs. 6,760/- for the policy. The complainant fell sick and had to undergo treatment for the kidney failure and has spent lot of money for his ailment. He has spent Rs. 62,395/-. He had made claim. He received letter on 12.06.2009 from the opposite party repudiating the claim on that ground that ailment was pre-existing. Complainant got issued legal notice to opposite party. The opposite party sent reply to the notice and also sent cheque and thereafter, complainant had issued rejoinder to the reply notice and opposite party has sent one more cheque for Rs. 4,050/-. Complainant has accepted the same. Since, policy renewed every year right from 2005 till date complainant is entitled for the benefit under the policy. Complainant suffered kidney failure and he has to undergo dialysis thrice a week and every time he has to pay Rs. 750/- for dialysis. It is a recurring expense for the complainant. The opposite party having accepted the policy for the year 2009-10 is liable to reimburse the expenses incurred by the complainant. The complainant prayed that opposite party be directed to pay Rs. 75,850/-. 2. Opposite party No. 1 submitted version stating that complainant has submitted claim for Rs. 62,395/- towards medical treatment. But according to the claim papers claim was made for Rs. 42,443/- only. The claim was settled for Rs. 36,787/- and cheque was given. Subsequent to the settlement of claim, the claim was again reopened by the opposite party and balance of Rs. 4,050/- was settled. Same was accepted by the complainant. 3. Opposite party No. 2 in his version submitted that hospitalisation benefit policy had been issued to the complainant. Sum insured is Rs. 1,00,000/-. Policy was being renewed from 2005-06. Complainant lodged claim with the opposite party for sum of Rs. 42,443/-. Complainant produced hospital documents including settlement receipts and bills for Rs. 42,443/- only. The complainant has not filed claim for Rs. 62,395/-. The claim for Rs. 42,443/- was received by opposite party No. 1. Claim was settled for Rs. 36,787/- and cheque was given. Another cheque for Rs. 4,050/- was given to the complainant after processing the claim. Sum of Rs. 1,606/- only was disallowed by virtue of terms and conditions of policy. Complainant had lodged claim papers pertains to the hospitalization for the period from 21.05.2009 to 24.05.2009 with the opposite party No. 1 claiming a reimbursement of Rs. 42,443/- out of which Rs. 40,837/- has already been paid and only sum of Rs. 1,606/- was disallowed. 4. Affidavit evidences are produced and documents are produced. 5. Arguments are heard. 6. The point for consideration is: Whether the complainant has proved deficiency of service on the part of opposite parties? 7. On perusal of the documents produced by the parties the complainant has submitted claim form Ex. R6. As per this claim form he has claimed total amount of Rs. 42,443/-. He has also produced hospital bills and settlement receipt. As per hospital bills also the amount is shown as Rs. 42,443/-. Except the Wockhardt hospital bills for Rs. 42,443/- the complainant has not produced any other bills of Wockhardt hospital. As regards Wockhardt hospital bills are concerned the opposite party has settled the claim. Cheques for Rs. 36,787/- and Rs. 4,050/- was given to the complainant and both cheques have been accepted by the complainant. In this way the opposite party has settled the claim of the complainant for Rs. 42,443/-. As per the Wockhardt Hospital bills are concerned the opposite party has reimbursed entire medical expenses to the complainant. It is the case of the complainant that he had also taken treatment in Sevakshetra Hospital, Bangalore and he has produced some bills of Sevakshetra Hospital and it is submitted that the opposite party has not settled the claim of the hospital bill of Sevakshetra Hospital. On perusal of the documents and the notice and reply notice exchanged by the parties it is very clear that the complainant has submitted claim form at Ex. R6 for Rs. 42,443/- only and not for Rs. 63,135/- as submitted by the complainant. The opposite party has admitted and settled the claim and given two cheques for Rs. 36,787/- and Rs. 4,050/-. The complainant has accepted the cheques. Therefore, opposite party has paid the entire amount of Rs. 42,443/- as per the claim form submitted by the complainant. If at all the complainant has spent more amount towards his treatment and it is the case of the complainant that he has taken treatment at Sevakshetra Hospital also and he has got hospital bills and papers to show that he has spent amount for his treatment in the hospital. In that case the complainant has to submit claim form to the opposite parties along with hospital documents, receipts and bills. Thereafter, the opposite party shall have to process the claim and settle the claim. In the absence of not submitting claim form to the opposite party it is very difficult to reimburse the Sevakshetra Hospital bills. First he has to submit claim form, documents and bills to the opposite party for settlement of the claim. In case the opposite party repudiates the claim then only the complainant has got right / cause of action to file the complaint. So under these circumstances the only remedy open to the complainant is to submit the claim form along with bills and documents of Sevakshetra hospital. I hope and trust that the opposite parties shall definitely consider the bills of hospital and settle the claim within the policy terms and conditions. Since the policy covers an amount of Rs. 1,00,000/- to that extent the opposite parties are within their right to settle the claim of the complainant. The opposite party shall settle the claim of the complainant as expeditiously as possible i.e. within 15 days from the date of submission of claim form by the complainant. The complainant is suffering from a very serious ailment and he has spent lot of money. Since, he has obtained mediclaim policy it is right to claim reimbursement of the hospital expenses. With this observation we are of the opinion that complaint is premature one since there is no repudiation of the claim of the hospital expenses of Sri Krishna Sevakshetra Hospital. Therefore, no direction could be given to the opposite parties for payment of amount. However, the complainant shall submit the claim form supported by documents to the opposite parties and I hope and trust that the opposite parties shall settle the claim of the complainant immediately as per law. With this observation the complaint deserves to be dismissed for the present giving liberty to the complainant to file complaint afresh in case his claim is not settled for any reasons by the opposite parties. 8. Send the copy of this Order to both the parties free of costs immediately. 9. Pronounced in the Open Forum on this 30TH DAY OF OCTOBER 2010. Order accordingly, PRESIDENT We concur the above findings. MEMBER MEMBER
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