Back
2025 Supreme(Online)(SCDRC) 7935
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Mr JUSTICE T G SHIVASHANKARE GOWDA, PRESIDENT, Mrs M DIVYASHREE, LADY MEMBER
Sri M Krishnappa – Appellant
Versus
The Manager M/s United Insurance TPA Pvt Ltd. – Respondent
Consumer Protection Act 2019 | SC/29/A/1253/2024
For the Appellants/Petitioners: In person
For the Respondents: Mr Krishna Kishore, Dr S V Joga Rao, Mr G B Sharath Gowda
The court held that senior citizens should receive fair compensation for mental agony, highlighting the obligation of insurance providers to honor their coverage commitments.
Headnote:(A) Consumer Protection Act, 2019 - Appeal against denial of cashless facility - The Appellant claimed reimbursement after treatment at a non-network hospital, alleging deficiency of service by the respondents - The District Commission awarded partial relief - The appellate court modified the compensation and interest awarded. (Paras 1-15)
(B) Appeal - Nature of appellate review - The court emphasized consideration of the appellant's senior citizen status and the need for fair compensation related to mental agony and litigational efforts. (Paras 13-15)
Facts of the case:
The Appellant, a retiree from Bharat Electronics, was denied cashless treatment for his wife at a network hospital and sought reimbursement, which was not honored, prompting a complaint for damages.
Findings of Court:
The court ruled on proper compensation for the appellant's expenses and distress, adjusting the awarded sum upwards due to the appellant's status and circumstances.
Issues: The core issues involved the adequacy of compensation and whether the appellant should receive reimbursement for medical expenses.
Ratio Decidendi: The appellate court held that the compensation awarded did not reflect the distress experienced by the appellant and thus warranted enhancement.
Result: Appeal is allowed in part with a modification of awarded compensation.
| Table of Content |
|---|
| 1. denial of cashless facility and claims (Para 3 , 4 , 5 , 6) |
| 2. duty of insurance providers (Para 8 , 9 , 10 , 11 , 12) |
| 3. appellate review concerns (Para 13) |
| 4. compensation modification (Para 14) |
| 5. final ruling and compensation award (Para 15) |
ORAL PER:Mr JUSTICE T G SHIVASHANKARE GOWDA: PRESIDENT This is an Appeal filed under Consumer Protection Act
2019 by the Complainant, challenging the Order dated 22.04.2024 passed in Consumer Complaint No.140/2023 by District Consumer Disputes Redressal Commission, Kolar (for short, the District Commission).
2. Appellant was the Complainant and the Respondents were OPs before the District Commission. For the sake of convenience, the rank of the parties shall be referred to as per the status before the District Commission.
3. The brief facts of the case are that, the Complainant is an employee of Bharat Electronics Company and he had retired in the month of June 2013. As per the Medical terms of the Company, the Complainant and his wife Smt Nanjamma both are having medical coverage for in-patient and out-patient treatment under the Medical Insurance Policy obtained from OP1. Till 2023, both the Complainant and his wife have been taking treatment at OP2 Hospital and availed cashless treatment facility. On 13.09.2023, Complainant had taken his wife Smt. Nanjamma to OP2’s Hospital, wherein, they declined to extend the Cashless Medical Treatment facility and informed them that they have received letter from OP1 that there are other Network Hospitals for retired employees to avail medical treatment. Since the cashless facility was not extended to the Complainants by OP2 Hospital, the Complainant got his wife treated by paying cash and he made a claim to the Insurance Company and which was not honoured. Hence, the Complainant filed the complaint before the District Commission alleging deficiency in service on the part of OPs seeking reimbursement of Rs.14,830/- with interest at 18% p.a, Rs. 2 lakhs as Compensation for mental agony and Rs.5,000/- towards litigation cost.
4. Before the District Commission, OP1 has filed his Version. OP2 has not filed Version. Though OP3 entered appearance, after placing him ex-parte, his belated Version was not taken on record.
5. Insurance Company though admitted the employment and retirement of Complainant No.1, it was their contention that wife of the Complainant had taken treatment less than 24 hours, hence she is not entitled for any reimbursement of amount spent towards treatment. The treatment taken by the wife of the Complainant was in a Hospital, which is not Network Hospitals and hence there is no deficiency in service on their part.
6. Before the District Commission, parties have led their evidence. The District Commission after hearing the arguments of the parties, by the Impugned Order, allowed the Complaint in part, directing the OP1 to reimburse the sum of Rs.14,830/- with interest at 18% p.a from the Date of Admission to the Hospital till its payment, Rs.2,000/- each as Compensation for mental agony and cost of the litigation. Aggrieved by the same, seeking enhancement, the Complainant has filed this Appeal, on various grounds.
7. We have heard Complainant in person and Mr. Yashwant Prasad, the learned Counsel appearing for OP2 and Mr G B Sharath Gowda the learned Counsel appearing for OP3.
8. It is the contention of the Complainant that, he being a Senior Citizen, took his wife - another Senior Citizen, to OP2 Hospital for treatment. Insurance Company is duty bound to provide cashless treatment facility and only on arrival at OP2 Hospital it was informed that they cannot extend the cashless treatment facility to take treatment in any other Network Hospital. Since the wife of the Complainant could not take treatment in the OP2 Hospital, they were constrained to avail treatment, by paying Cash and reimbursement Claim was made to the Insurance Company, which was not reimbursed. It was also one of the contentions of the Complainant that,
