State Consumer Disputes Redressal Commission
The National Insurance Co. Ltd., vs Sri.Shivappa, & Ano., on 9 August, 2011
BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE Appeal No.210/2011 Filed on 21/01/2011 Disposed Off 09/08/2011 BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE. DATED THIS THE 09th DAY OF AUGUST 2011 PRESENT HONBLE JUSTICE MR.K. RAMANNA : PRESIDENT SRI. A.M. BENNUR : MEMBER
SMT. RAMA ANANTH : MEMBER Appeal No.210/2011 The Divisional Manager, The National Insurance Co. Ltd., Biolgundi Complex, Station Road, Opp. Mini Vidhanasoudha, Gulbarga, Repted by its Regional Manager, The National Insurance Co., Ltd., Regional office, No.144, Subharam Complex, M.G.Road, Bangalore-01.
.....Appellant O.P.1 before D.F. (By Shri/Smt. R.B.Raju & P.S.Jagadish, Advs) V/s
01. Sri.Shivappa, S/o Eshwarappa Rastapur, Aged about 53 years, Occ Private Service, R/o Shahabad, Chithapur Taluk, Gulbarga District.
Respondent No.1 Complainant before the D.F.
02. The Manager, MD India Health Care Services, (TPA PVT.
LTD., Bangalore Branch, 90/2, I & II Floor, K.H.Road, Near BMTC Bus Depot, Blore.
Respondent No.2 O.P-2 before the D.F. (by Shri/Smt. Saritha Kulkarni, Adv) (Re2 served absent) :-O R D E R:-
BY HONBLE JUSTICE SRI K. RAMANNA : PRESIDENT This appeal is filed by the O.P.1 Challenging the correctness and legality of the order dated 25/11/2010 passed by the D.F.Bulbarga in C.C.No.161/2010, wherein and whereby the complaint filed the respondent No.1 came to be allowed in part directing the appellant and respondent No.2 jointly and severally to pay Rs.83,000/- towards hospitalization charge together with interest @ 9% p.a. from the date of filing of the complaint till realization and further directed to pay Rs.5,000/- towards compensation and Rs.2,000/- towards cost of the proceedings. Being aggrieved by the same, the O.P.No.1 has come up with this appeal on various grounds.
2. He has also filed an application U/s 5 of the Limitation Act to condone the delay in preferring this appeal supported by an affidavit of Usha Nandakuamr the Assistant Manager of the appellant.
3. The case of the respondent No.1 in brief is that:-
The respondent No.1 has purchased a family health hospitalization benefits insurance policy from OP1 through OP2. He has paid premium of Rs.9,744/- to OP1. The said insurance coves the entire family members of the policy holder. The policy was in force from 15/02/2001 to 14/02/2011. The wife of respondent No.1 admits to Yashodha Hospital, Hyderabad for Hernia and Gall Bladder diseases and was an inpatient from 19/03/2010 to 22/03/2010. The complainant has spent Rs.1,36,686/- with discount of Rs.5,686/- towards his wifes medical treatment. The respondent No.1 made a claim for Rs.1,31,000/- though he was entitled for Rs.1,25,000/- plus bonus amount of Rs.13,750/-. But the appellant paid only Rs.46,000/-. The respondent No.2 further sent cheque only for Rs.2,000/-. The demand made by respondent No.1 to make remaining amount of Rs.83,000/-, went in vain. Therefore, he filed a complaint to direct the appellant to Rs.83,000/- with interest at 12% p.a. from the date of claim till realization.
4. In spite of noticed issued to Ops by the D.F. the respondent No.2/O.P.2 remained absent.
But the appellant/O.P.1 appeared and resisted the complaint by filing version.
5. We have heard the arguments of the counsel for appellant and also for respondent and perused the records.
6. The points for determination:-
(1) Whether the appellant has shown sufficient and reasonable grounds to condone the delay in preferring the appeal?
(2) Whether the D.F. is justified in allowing the complaint filed by the respondent?(2)
If so, what order?
7. Our answers are:-
Point No(1) : In the Affirmative Point No(2) : In the Negative Point No.(3): As per final order for The following:-
:-REASONS:-
Point No (1):-
8. As far as I.A.I is concerned, one Usha Nandakumar, the Assistant Manager of the appellant company has explained about the delay in the affidavit stating that after passing the impugned order25/11/2010, they received certified copy on 02/12/2010. Thereafter their dealing advocate has forwarded the same along with his opinion to the insurance Company, Gulbarga i.e., policy issuing office. After receiving the opinion fro their Divisional office at Gulbarga, they forwarded the same to the regional office at M.G.Road, Bangalore and thereafter the papers were entrusted to the senior counsel and after obtaining opinion about filing appeal, they preferred this appeal. Hence, in that process, the delay has occurred. The delay is unintentional and bonafide. Therefore, he requested to condone the delay. The appellant is a public company, if they have to prefer an appeal they have to make some correspondence between them and to get legal opinion in preferring the appeal. Hence, in that process, some delay may be occurred. Therefore, we are satisfied about the reasons assigned by the appellant. Hence, the delay is condoned and I.A.1 is allowed.
Point Nos. 2 & 3:-
9. On careful scrutiny of the order under challenge, it reveals that the respondent No.1 has obtained family health Hospitalization Benefits Insurance Policy from the appellant by paying premium of Rs.9,744/-. As per the terms and conditions of the policy, the policy covers the entire family members of the respondent No.1. The main purpose of taking the policy like Family Health Hospitalization Benefits Insurance Policy in the event of getting reimbursement of the amount spent towards medical expenses/hospitalization charges either of the insurer or the family members hospitalized due to any illness. Therefore, the issuance of the policy by the appellant in favour of the respondent No.1 is not in dispute.
10. The appellant admits that the policy issued to him is valid for the period from 15/02/2001 to 14/02/2011. The treatment undergone by the wife of the respondent No.1 by name Nandamma at Yashodha Hospital, Hyderabad in between 19/03/2010 to 22/03/2010 for Hernia and Gall Bladder diseases. According to the respondent/complainant he has incurred expenses of Rs.1,36,686/-. The Hospital authorities has given him discount of Rs.5,686/-. Of-course there is no dispute with regard to the payment of Rs.48,000/- by the appellant by way of reimbursement though the respondent No.1 spent Rs.1,31,686/-.
11. The sum assured was Rs.50,000/- and C.B. is Rs.7,500/-. Therefore, in the year 2005-06 the sum assured was Rs.50,000/- and C.B. is Rs.2,500/-. Likewise the details of the sum insured are shown at page4 of the memorandum of appeal. Of-course for the 1st year the respondent No.1 is not entitled for C.B. From 2006 onwards up-to 2009 he is entitled to C.B. benefit of Rs.7,500/-. Whereas in the year 2009-10, the sum assured was Rs.75,000/- and C.B. is Rs.10,000/-. Therefore, the respondent has enhanced the premium, consequently sum assured was for the year 2010-11 is Rs.1,25,000/-. Accordingly the respondent No.1 is entitled to Rs.13,750/- of C.B.
12. It is contended by the counsel for the appellant that the respondent No.1 claimed additional amount ofRs.85,000/- and the claim was settled by sending additional amount of Rs.2,000/- as applicable. Since the respondent took the policy for the year 2008-09 and the sum assured isRs.50,000/- and the C.B. is Rs.7,500/-. Therefore the appellant paid Rs.46,000/- and later he has paid Rs.2,000/-, in all Rs.48,000/-. But the D.F. under the impression that the respondent had spent Rs.1,31,000/-, whatever the amount spent towards hospitalization charge, has been awarded. Therefore the D.F. without considering the facts and circumstances of the case, come to the conclusion and passed the impugned order. Therefore, the D.F. come to erroneous conclusion without considering the main object of issuing such type of policy i.e., Family Health Hospitalization Benefits Insurance Policy. Therefore, we re of the considered opinion that the matter requires remand for reconsideration of the oral and documentary evidence placed in record by both the parties and go through the policy and terms and condition of the policy.
Therefore, we hold that the order under challenge is liable to be set-aside and the matter requires to be remand for fresh adjudication by allowing both the parties to adduce further evidence if any and dispose off the matter in accordance with law keeping in mind the observations made by this Commission referred above. Accordingly we answer the point and proceed to pass the following:-
:-ORDER:-
The appeal is allowed.
The impugned order dated 25/11/2010 passed by the D.F.Gulbarga is hereby set-aside.
The matter is remitted back to the D.F., Gulbarga by giving an opportunity to both parties to adduce further evidence if any and to dispose off the matter in accordance with law.
Both parties are directed to appear before the D.F.Gulbarga on 09/10/2011.
The amount deposited if any by the appellant shall be refunded to the appellant.
MEMBER PRESIDENT MEMBER TSS**