State Consumer Disputes Redressal Commission
New India Assurance Co. Ltd., vs Ganashyamadas A. Thakur, on 8 February, 2010
AppelliNo.2315/2009
Appelli filed on: 14-07-2009
Appelli Disp.on: 08-02-2010
BEFORE THE KARNATAKA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION, BANGALORE.
Appeal No.2315/2009
New India Assurance Co. Ltd.,
B.H.Road, Tumkur.
By Divisional Manager,
New India Assurance Co. Ltd.,
Mayur Complex,
KIADBMain Road, Peenya,
Bangalore.
By its Manager. Opposite Party-3 before the DF
....Appellant
(By Shri. O. Mahesh)
Ganashyamadas A. Thakur,
Aged 59 years,
Proprietor,
M/ s.Amarjyothi Textiles,
Jai Bharath Towers,
Vivekananda Road,
Tumkur - 572 101. Complainant before the DF
.... Respondent
ORDER,
SRI. T. HARIAPPA GOWDA, MEMBER
OP-3 aggrieved by the order of the District Consumer Disputes Redressal Forum, Tumkur In C.C No.37/2009 dated 15.06.2009 has filed this appeal.
2. The facts of the complainant case'before the DF is that, the complainant has taken a medi-claim policy from the OP's branch office at Tumkur. The policy covered for himself, his wife, two sons and daughter. On 24.01.2008, he paid the first premium of Rs.10,326/-. The policy was valid from 24.01.2008 to 23.01.2009. He had renewed the policy by paying the premium. The complainant and his family members were covered under the policy are also card holders of M/ s.TTk Health Care Services Pvt Ltd. The complainant's wife had undergone treatment as in-patient from 10.05.2008 to 13.05.2008. After examination, the doctors advised the wife of the complainant to use CPAP at night with 1-2 litre oxygen/mnt to prevent long term complications. On 25.07.2008 Dr.H.V.Suryanarayana Rao, Pulmonologist has issued a letter. As per the advice of the said doctor, the complainant purchased the instrument from M/ s. Sumukha Enterprises, Bangalore in his wife's name on 26.07.2008 for Rs.72,000/-. The complainant's daughter Miss.Lakshmi G. Thakur had claimed total treatment charges of Rs.22,200/- but OP-4 has paid only Rs.15,000/- and balance of Rs.7,200 j - has not' been paid. In spite of several attempts OP-3 and 4 have not given any positive reply to him. On 01.12.2008 the complainant sent xerox copy of the related papers and treatment details to the OPs through courier but OPs have not gIven any response. On 12.02.2008 the complainant got issued notice to OPs through RPAD but even after receipt of notice, the OPs have not given any reply. Therefore, the complainant alleging deficiency of service by the, OPs has filed the complaint against the OPs to pay him Rs.72,000j- towards cost of the CPAP and the balance amount of treatment charges of his daughter of Rs.7,200 j- along with interest and 'compensation of Rs.50,000 j - towards mental agony and deficiency of service and Rs.1 ,500 j - towards legal notice charges and other expenses.
3. The DF accepting the case of the complainant allowed the complaint in part and directed OPs.1 to 3 jointly and severally to pay Rs.79,200j- + Rs.5,000j- within 8 weeks from the date of order and ordered payment of interest at 10% p.a from the date of complaint till realization on the failure of the OPs to pay the amount within 8 weeks. The DF has further directed the OPs to pay Rs.1,000j- as costs and Rs.10,000j- as punitive damages and directed payment of Rs.5,000 j - out of punitive damages to the complainant and to deposit the balance amount to the Consumer Legal Aid maintained by the Forum.
challenge in this appeal.
4. We have heard the Learned Counsels appearing for the Appellant/OP-3 and Respondent/Complainant. We have perused
5. There is no dispute that the complainant has taken the mediclaim policy from the OPs. According to the complainant as per the advice of the doctor, he purchased CPAP for the use of his wife, who had taken treatment as in-patient in M/s.Bhagwan Mahaveer Jain Hospital, Bangalore from 10.05.2008 to 13.05.2008. It 1S the further case of the complainant that one Dr.H.V.Suryanarayana Rao, issued a letter and on the basis of the said letter, he purchased the instrument for Rs.72,000 / -. It is his further case that though he has spent 'Rs.22,200 / - towards the treatment of his daughter, OP-4 has paip only Rs.15,000/- and did not pay the balance of Rs.7,200} - without any reasons. OPs.1 to 3 have filed objections before the DF mainly contending that the poli~y covered medical expenses through hospitalization and as per the exclusion clause 4.4.4 the cost incurred by the policy holder for the purpose of purchasing equipment is not covered and therefore the complainant is not entitled for reimbursement of Rs.72,000/-. They have also contended that' as for as the claim of the complainant in respect of the treatment to his daughter is concerned, they have paid the amount as per the policy. They have contended that there is no defic~encyof ~ervice on their part. purchased by the complainant to his' wife does not come within the not liable to reimburse the cost. In this connection, it is seen from complainant is in fact a Pacemaker and it is covered under clause 1 "1.0 In the event 'of anyclaim/s becoming admissible under this Scheme, the company will pay to the insured person the amount of such expenses. as would fall under different heads mentioned below, and as are reasonably and necessarily incurred thereof by or on behalf of such insured person, but not exceeding the sum insured In aggregate mentioned in the schedule hereto:
(A) Room, Boarding expenses as provided by the Hospital/Nursing Home.
(C) Surgeon, Anaesthetist,¥~di~al Practitioner, Consultants, Specialists fe~s.
(D) Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Applianc~s, Medicines and Drugs, Diagnostic materials and x-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs and Cost of Organs and similar expenses".
complainant is not Pacemaker, in our opinion the OPs are not purchased the instrument CPAP by paying cost of Rs.72,000 / -. If that is so, in our view, the DF is justified in allowing the complaint medical expenses of his daughter, he has claimed a sum of Rs.22,200 /-, but OP-4 has paid on,ly Rs.15,000 /-. In this 'v connection, OP-4 has not produced any material before the DF as to why out of the total claim only Rs.l'5,OOO/- was paid to the complainant. In that event, the DF i~ also ,right in directing the OP to pay the balance amount of Rs.7,209/"" towards medical expenses of the daughter of the complainant.
9. However, apart from awarding damages to the complainant the DF has also directed OPs.l to 3 to pay punitive damages of Rs.l 0,000/-. In our opinion when damages and interest has been awarded to the complainant, there was no. reason to award punitive damages to the complainant. Therefore the impugned order requires modification to that extent. Hence, we pass the following:
In modification of the order of the DF, we direct OPs.1 to 3 to pay jointly and severally Rs.84,200 /- to the complainant within 8 weeks from the date of the order of the DF failing which they shall pay interest at 10% p.a from the date of the complaint till realization.
The direction of the DF to the OPs to pay the cost of Rs.1,000/- is kept undisturbed. The appeal is disposed off accordingly.
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