IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAMBALPUR.
CONSUMER COMPLAINT NO.94 OF 2008
Subrat Dash,
S/O. Late Ram Chandra Dash,
At: Bhim Bhoi Nagar, P.O.: Budharaja,
P.S.: Ainthapali, District: Sambalpur. …….. Complainant.
Vrs.
1. The Divisional Manager,
United India Insurance Co. Ltd.,
2nd Floor, Posenette Bhawan,
Ramkote, Tilak Road,
Hyderabad(Andhra Pradesh),
2. Chief Executive Officer, representing
Family Health Plan Limited,
Aditya JR Towers, 8-2-120/86/9/A&B,
Road No.2, Banjara Hills
Hyderabad, Andhra Pradesh.
3. Senior Executive(Corporate Relations),
Family Health Plan Limited,
Plot No.268, Kharvel Nagar, Unit-III,
Bhubaneswar, Orissa-751 001.
4. Branch Manager,
Andhra Bank G.M.College Road,
Sambalpur. ,,,,,,,, Opp.Parties.
For Complainant: Shri A.K.Ghose, Advocate.
For O.P.No.1 : Shri S.A.Guru, Advocate.
For O.P.Nos.2 & 3: None.
For O.P.No.4: Shri P.N.Singh Deo &
Shri S.K.Mahapatra, Advocates.
DATE OF ORDER : 18.04.2009
P R E S E N T :
SHRI A.K.PUROHIT, PRESIDENT
A N D
SHRI T.JAYAPURIA, MEMBER.
Contd…2.
SHRI A.K.PUROHIT,. PRESIDENT: – The case of the complainant is that the O.P.No.2, being the franchise of the O.P.No.1 for Mediclaim Insurance Policy has started its business through O.P.No.4, Andhra Bank at Sambalpur. The complainant an account holder of the Andhra Bank, on the request of the Branch Manager of the Bank had taken a Mediclaim policy for an amount of Rs.1,00,000/-(Rupees One Lakh) and paid the annual premium of Rs.1,837/- vide Policy No.050400/48/06/41/00000116. The said policy is for the benefit of the complainant, his wife, his son and his daughter. The policy is valid for a period from 9.6.2006 to 8.6.2007. Due to complain of stomach pain, the wife of the complainant was admitted in the Healing Touches Nursing Home on dt.24.2.2007 during the validity of the policy and after required tests, she had undergone operation and spent Rs.16,893/- towards the charges of the Nursing Home. After discharge from the Nursing Home, the complainant lodged his claim before the O.Ps. But the said claim was refuted by the O.Ps on the ground that the complainant has not produced the money receipts of individual doctors. To this the complainant has sent a Notice through his Advocate for settlement of his claim. But the O.Ps demanded the same document which is not possible for the complainant as his wife was operated by the doctors engaged by the Nursing Home. Hence the complaint.
2. The O.P.No.1 & O.P.No.4 have filed their written version separately. In his written version the O.P.No.4 has denied all the allegations of the complainant and averred that, he being a Nationalized Bank has acted as a facilitator of the O.P.No.1 and accordingly, on the request of the complainant, the O.P.No.4 supplied a Mediclaim form and advised the complainant to submit the same before the O.P.No.3. The O.P.No.4 claims no deficiency in service on his part. In his written version the O.P.No.1 has admitted the policy of the complainant and its validity and submitted that as per the I.R.D.A., Regulations, 2001, the O.P.Nos.2 & 3 are appointed as third party administrator for process of claim applications. After receipt of the claim of the complainant, the O.P.Nos. 2 & 3 have doubted the engagement of three surgeons by the Nursing Home as only the name of Dr.A.K.Singhal has been mentioned in the claim form. Hence they asked for money receipt of the individual doctors, which the complainant unable to produce and accordingly, the claim was rejected. The O.P.No.1 denied all the allegations of the complainant and claims no deficiency in service in service on his part.
3. Heard both the parties and perused the documentary evidence available on record. The Learned Advocate for the O.P.No.1 argued on behalf of O.P.Nos. 1 to 3 and submitted that , to know about the real expenses , money receipt of individual doctors is necessary and it is the bound down duty of the complainant to supply the same, to which the complainant fails and the claim has not been proceeded. Hence, there is no deficiency in service on the part of the O.Ps. On the other hand the Learned Advocate for the complainant submitted that the doctors have been engaged by the Nursing Home and as such the complainant was unable to bring individual receipts and on this ground alone the O.Ps can not escape from their liability.
4. Perused the documentary evidence available on record. It is an admitted fact that the complainant had taken a Mediclaim policy from the O.Ps which covers the Family Health Plan of the complainant, his wife, son and daughter and is valid from 9.6.2006 to 8.6.2007. It is seen from the discharge slip of the Healing Touches Nursing Home that Mrs. Indira Das, wife of the complainant was admitted on dt.24.2.2007 in the Hospital and discharged on 26.2.2007, where she was operated under Laparoscopic process. It is also seen from the Bill No.45/07 dt.27.2.2007 of the Hospital that the complainant had paid Rs.16,893/- for all the expenses of the Hospital. It is a common knowledge that, when a patient is admitted to a Nursing Home, he has no choice to contact any individual doctors nor is paying the expenses to the doctors individually. Therefore, it is believed that the complainant had paid all the expanses to the Nursing Home vide Bill No.45/07. The O.Ps have not produced any evidence to show that they have conducted any enquiry through their own agent nor have produced any affidavit evidence to show that the claim of the complainant is not a genuine one. There is also no such policy condition for supply of money receipt of individual doctors.
5. With these evidences available on record, it can not be said that the repudiation of the claim is justified. The non-settlement of the claim of the complainant by the O.P.Nos. 1 to 3 amounts to deficiency in service on their part. The O.P.No.4 has simply supplied the policy form and has submitted before the Insurance Company and there is no evidence on record to prove any liability of the O.P.No.4. It is the Insurance Company, who is liable for the claim of the complainant. The complainant has also not claimed any specific relief against the O.P.No.4. Hence there is no deficiency in service on the part of the O.P.no.4. Hence order:
The complaint petition is allowed. The O.P.Nos.1, 2 & 3 are directed to
pay Rs.16,893/-(Rupees Sixteen thousand eight hundred ninety three)
jointly and severally to the complainant along with Rs.5,000/-(Rupees-
-Five hundred) towards cost of the proceeding within one month from
the date of receipt of this order, failing which the entire awarded
amount shall carry interest at the rate of 8 (Eight) per cent per annum
from the date of order till payment. The case is dismissed against the
O.P.No.4.
The case is disposed of accordingly
SHRI A.K.PUROHIT
PRESIDENT
SHRI T.JAYAPURIA, MEMBER. I agree.
Dictated and corrected by me.
PRESIDENT.