IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Tuesday the 31st day of May, 2016
Filed on 27.11.2015
Present
- Smt. Elizabeth George (President)
- Sri. Antony Xavier (Member)
- Smt.Jasmine.D. (Member)
in
C.C.No.346/2015
between
Complainant:- Opposite Parties:-
Smt. Ambika Devi.L. 1. The Managing Director
W/o S.K. Narendra Dev Vidal Health TPA Pvt. Ltd.
Anizhom, GNRA – 40 Anmol Palani # 88, L2
Pazhaveed P.O. GN Chetty Road, T. Nagar
Alappuzha – 688 009 Chennai – 600 017
(By Adv. T.N. Maurice Vincent)
2. The Administrative Officer
Rajagiri Hospital
Chunangamveli P.O.
Aluva
(By Adv. Sindhu. N.G.)
O R D E R
SMT. JASMINE. D. (MEMBER)
The case of the complainant is as follows:-
The complainant is a retired officer from Indian Overseas bank. The complainant availed an insurance policy from the first opposite party through her employer Indian Overseas bank. While so when the policy was in existance she was admitted at Rajagiri Hospital, Chunangamveli P.O., Aluva for Osteoarthritis B/L Knee and there she underwent a surgery for her right knee to implant sticker in the right knee. The complainant who is a valid policy holder of the first opposite party is liable to compensate the medical expenses incurred by the complainant for the above said surgery. She had spent a total amount of Rs. 1,76,112.46/- for the surgery. The complainant applied through her employer for the reimbursement of the medical expenses incurred 6.7.2015. But the first opposite party has not effected the payment claiming that the complainant has not produced the invoice bill of the implant sticker which was used to implant the complainant’s knee. The complainant explained the reason for not producing the bill of the implant sticker on different days and finally she sent a legal notice on 27.10.2015. But the opposite party has not given any reply. The complainant sustained much mental agony and hence filed this complaint seeking reimbursement of the medical expenses incurred by her.
2. Notices were served to the opposite parties. First opposite party has not appeared before the Forum, hence first opposite party was set ex-parte. 2nd opposite party appeared before the Forum and filed version.
3. The version of the 2nd opposite party is as follows:-
The 2nd opposite party is not a necessary party in this case. In this case the 2nd opposite party has successfully done its job and on the request of the complainant the entire hospital bills were given. It is pertinent to note that on going through the petition throughout there is no any allegations, in the complaint against the second opposite party. There is no deficiency in service on the part of the 2nd opposite party. The complainant has not an intention to prosecute or proceed against the 2nd opposite party. Since the 2nd opposite party is not a necessary party in this case, the matte in disputes need not be adjudicated with the 2nd opposite party. There is no cause of action is against the 2nd opposite party and no deficiency in service is alleged against the second opposite party. Hence he prayed to stop the proceedings against the second opposite party.
4. The complainant filed proof affidavit and documents marked as Ext.A1 to A8 were marked.
5. The points that arose for consideration are as follows:-
1) Whether there is any deficiency in service on the side of the opposite parties?
2) If so the reliefs and costs?
6. The case of the complainant is that the complainant is a retired officer from the Indian Overseas bank, has availed a policy from the first opposite party through her employer Indian Overseas bank. During the existence of the policy, the complainant was admitted at Rajagiri Hospital, Aluva and underwent a surgery in the right knee to implant sticker. The complainant has incurred total expenses of Rs.1,76,112.46/-. Since the complainant is a valid policy holder of the first opposite party, the first opposite party is bound to reimburse the medical expenses incurred by her. But the opposite party failed to provide the benefits alleging that she has not produced the invoice bill of the implant sticker. The complainant sustained much mental agony, hence filed this complaint seeking reimbursement of the medical expenses incurred by her along with costs.
7. The complainant filed proof affidavit and Exts.A1 to A8 were marked. Ext.A1 is the copy of application for reimbursement dated 6.7.2015 along with the inpatient bill, Ext.A2 is the copy of reminder letter dated 16.10.2015 issued by the first opposite party, Ext.A3 is the copy of lawyer’s notice dated 27.10.2015, Ext.A4 is the postal receipt, Ext.A5 is the acknowledgement card, Ext.A6 is the copy of the discharge slip issued from Rajagiri Hospital, Ext.A7 is the letter dated 25.9.2015 issued from the Rajagiri Hospital and Ext.A8 is the copy of the details of inpatient bill. From the documents it can be seen that the complainant was admitted at Rajagiri Hospital on 16.6.2015 and there she underwent a surgery in her right knee to implant sticker and she was discharged on 24.6.2015. Further on a perusal of the document Ext.A7 it is clear that the opposite party Rajagiri Hospital was charged an amount of Rs.77,450/- for the implant sticker. According to the complainant the hospital purchased a bulk quantity of implant sticker for a large sum and out of that a single sticker is used to the complainant for her surgery. Separate invoice bill will not be provided for a single implant sticker. Its value can be clearly seen from the Ext.A7 document. Therefore the opposite parties are liable to disburse the entire claim amount of the complainant as she is a valid policy holder of the first opposite party. Since the first opposite party failed to provide the policy benefits, they have committed deficiency in service. The complainant is entitled to get the insurance claim. On going through the document, it can be seen that the 2nd opposite party has no role in the instant case. Hence we cannot hold that the 2nd opposite party is liable for any deficiency in service. But the 1st opposite party is liable to pay the medical expenses incurred by the complainant, so the complaint is allowed.
In the result, the complaint is allowed the first opposite party is directed to pay the medical expenses of Rs.1,76,112.46/- (Rupees one lakh seventy six thousand one hundred and twelve only) to the complainant. The first opposite party is further directed to pay an amount of Rs.2,000/- (Rupees two thousand only) towards costs of this proceedings to the complainant. The order shall be complied within one month from the date of receipt of this order failing which the amount of Rs.1,76,112.46/- shall carry interest @ 10% interest per annum from the date of order till realization to the complainant.
Dictated to the Confidential Assistant transcribed by her corrected by me and pronounced in open Forum on this the 31st day of May, 2016.
Sd/- Smt.Elizabeth George (President) :
Sd/- Sri. Antony Xavier (Member) :
Sd/- Smt.Jasmine.D. (Member) :
Appendix:-
Evidence of the complainant:-
Ext.A1 - Copy of application for reimbursement dated 6.7.2015 along with the
inpatient bill
Ext.A2 - Copy of reminder letter dated 16.10.2015 issued by the first opposite party Ext.A3 - Copy of lawyer’s notice dated 27.10.2015
Ext.A4 - Postal receipt
Ext.A5 - Acknowledgement card
Ext.A6 - Copy of the discharge slip issued from Rajagiri Hospital
Ext.A7 - Letter dated 25.9.2015 issued from the Rajagiri Hospital
Ext.A8 - Copy of the details of inpatient bill
Evidence of the opposite parties:- Nil
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:- pr/-
Compared by:-
