State Consumer Disputes Redressal Commission
Ms. Simran Sultana vs E.Meditek (Tpa) Service Ltd., on 7 February, 2014
BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD. FA 577 of 2013 against CC 37/2012, Dist. Forum, Medak at Sanga Reddy Between: Ms. Simran Sultana D/o Ghouse Pasha, Aged 23 years, Occ: Business, R/o H.No. 11-63, Khaja Street, Narsapur (V & M), Medak District-502 313. *** Appellant/ Complainant And 1. E.Meditek (TPA) Service Ltd., 208-209, TURF Estate Office, Dr. E-Moses Road, Near Mahalaxmi, Mahalaxmi, Mumbai 400 011. 2. Rajnikanth Vurimi Head New Business Processing, SBI Life Insurance co. Ltd. At Mumbai, C/o E. Meditek (TPA) Service Ltd., 208-209, TURF Estate Office, Dr. E-Moses Road, Near Mahalaxmi, Mahalaxmi, Mumbai 400 011. 3. Ghouse Pasha S/o Amjad Ali, Servicing Agent / Facilitator, (IA Code 990271245), R/o H.No 14-9, Khaji Street, Post and Mandal Narsapur, Medak District., A.P. *** Respondents/ Opposite Parties Counsel for the Appellant: M/s. V.V. Patil Counsel for the Respondents: Served. CORAM: HONBLE SRI JUSTICE GOPALA KRISHNA TAMADA, PRESIDENT & SRI S. BHUJANGA RAO, HONBLE MEMBER
Oral Order: 07/02/2014.
(Per Honble Justice Gopala Krishna Tamada, President) ***
1) Complainant is the appellant and she approached this Commission questioning the order passed by the Dist. Forum, Medak at Sangareddy in CC No. 37/2012 dt. 17.6.2013 whereby her claim for an amount of Rs. 2,40,000/- towards medical expenditure for treatment was denied.
2) The brief facts that led to filing of this appeal are that the appellant/complainant obtained SBI Life Insurance Daily Hospital Cash Policy from the Opposite Parties 1 & 2 by remitting premium amount on 10.2.2012 and the period which was covered under the said premium is 10.2.2012 to 9.2.2013. As she fell ill, she was hospitalized and had undergone treatment from Siri Maternity & Nursing Home at Narasapur for a period of 45 days i.e., from 6.4.2012 to 23.5.2012. Immediately, after discharge she brought the said fact to the notice of respondents/opposite parties. As there was no response, a legal notice was issued claiming total sum of Rs. 2,40,000/- towards medical expenses, however, as the same was not settled, stating that there was deficiency of service, she approached the Dist. Forum and filed the said CC.
3) The Opposite Parties 1 & 2 though were served with notices have not contested the matter and thus remained ex-parte.
4) The Opposite Party No. 3 who collected the said premium from the complainant on behalf of Opposite Parties 1 & 2 filed a formal written version admitting the fact with regard to the policy obtained by the appellant/complainant.
5) After considering the affidavit evidence on behalf of the appellant/complainant and the documents Exs. A1 to A11 marked on her behalf, the Dist. Forum had come to the conclusion that the appellant/complainant had not produced any medical bills to establish that she incurred a total sum of Rs. 2, 40,000/- towards medical expenditure and thus dismissed the complaint. The Dist. Forum further held that said admission etc., in the said hospital is contrary to terms and conditions of the policy which was marked as Ex. A6.
6) When the appeal is filed notices were ordered to the respondents but none of the respondents have chosen to put in their appearance and accordingly they were set-ex-parte.
7) Heard the counsel for the appellant.
8) We are in total agreement with the order passed by the Dist. Forum. Ex.
A6 is the policy and condition No. 10deals with Claims. According to clause 10.6 Any hospitalization should be intimated to us before the hospitalization in case of pre-planned hospitalization or within 24 hours in case of emergency. In the instant case, even according to the appellant/complainant when she went to the said hospital as stated supra it was diagnosed as Enteric Fever with Hepatitis, and she was advised to be admitted in the hospital and accordingly she was admitted in the hospital on 6.4.2012. Even if it is treated as an emergency case, she should have informed the same to the insurer within 24 hours as per the said policy i.e., clause 10.6. In the instant case, the appellant/complainant informed the same after her discharge from the hospital on 23.5.2012 i.e., about one and half months which is contrary to the said policy. This aspect was taken into consideration by the Dist. Forum in rejecting her claim. The exclusion term of the policy must be read, so as to serve the main purpose of the policy, that is to indemnify the insured, and it cannot be said to be such a fundamental breach.
9) Similarly, there is another clause i.e., Clause 14 which deals with Complaints and a detailed Grievance Redressal Procedure is provided for in cases of this nature but the appellant/complainant admittedly did not follow the said procedure and straightaway approached the Dist. Forum for redressal of her grievance. In those circumstances, we are in agreement with the order passed by the Dist. Forum.
10) But the fact remains that the appellant/complainant was in the hospital from 6.4.2012 to 23.5.2012 and the same is established from the discharge summary which was marked as Ex. A10 given by the concerned hospital. Ex. A10 is given by Siri Maternity & Nursing Home, Narsapur, Medak District and the doctor is a qualified doctor and is an authorized doctor for LIC, SBI etc. From Ex. A10 it is clear that she was admitted to the hospital on 6.4.2012 and was discharged on 23.5.2012 and the complainant was treated for Enteric Fever with Hepatitis. From the above, it cannot be said that there was no treatment. In those circumstances, we are inclined to award a sum of Rs. 50,000/- towards medical expenditure.
11) Accordingly this appeal is disposed of. No costs.
1) _______________________________ PRESIDENT
2) ________________________________ MEMBER *pnr UP LOAD O.K.