18.8.08<br /> Sri.K.Gopalan, President<br /> <br /> This is a complaint filed under section 12 of the consumer protection Act for an order directing the opposite parties to pay Rs.13, 656/- with interest @ 9% and<br /> Rs.25, 000/- as compensation with cost.<br /> The case of the complainant in brief is as follows: The complainant is working in Gulf country. The complainant became a member under the Scheme Pravasi Suraksha Kudumbna Arogya Scheme. Complainant paid the premium of Rs.3, 490/- on 3.9.1999. The period of insurance is for five years from 3.9.1999 to 2/9/2004. Complainant underwent two major operations for his eyes at Dhanalakshmi Hospital, Kannur. All the necessary bills and documents related with the first operation forwarded to1st opposite party. But the opposite party did not settle the matter. Registered notice sent on 5.1.04 with a demand to pay the amount covered in both bills. After receiving the notice, the opposite party made a payment of Rs.5, 344/- only instead of paying Rs.19, 000/-. The opposite party is liable to pay the balance amount. Because of the deficiency in service by not paying the balance amount complainant sustained pecuniary and non pecuniary losses. . Hence this complaint.<br /> On receiving the complaint notice sent to parties and opposite party appeared and filed version denying the averments and allegations of complainant. The contentions of opposite party in brief are as follows: - The averment in the complaint that the complainant had undergone 2 operations for eyes and he had submitted the claim forms and the bills of both operation and treatment expenditure of both the operations conducted to his eyes are all false. The opposite party has got only one claim form from the complainant along with bills for Rs.5, 654.70 and claiming compensation for <br /> Rs.5, 654.70. The claim form and medical certificates was pertaining to the treatment he had undergone for the period from 4.12.01 to 8.12.01 at Dhanalakshmi Hospital, Kannur. The opposite party had processed the claims as per the claims form and had settled the claim as full and final settlement by paying the complainant Rs.5, 344/- against claims for<br /> Rs.5, 654.70. The complainant had never submitted any claims form for the treatment following the alleged operation he had undergone on 16.11.02. On receipt of the lawyer notice dated 15.1.04 the opposite party verified whether any document and claim form pertaining to the 2nd operation on 16.11.02 was submitted. No such claim filed. Opposite party did not get any enclosure with the notice also. Therefore opposite party settled the claim of the 1st operation alone for a sum of Rs.5, 344/-. The opposite party is not able to settle the claim of the complainant for Rs.8000/- towards the treatment following the 2nd operation only because he had not submitted the claim form along with medical bills and certificates.<br /> On the above pleadings the following issues were taken into consideration.<br /> 1. Whether there is any deficiency in service on the part of the opposite parties?<br /> 2. Whether the complainant is entitled for the remedy as prayed in the complaint?<br /> 3. Relief and cost.<br /> The evidence consists of oral testimony of complainant and opposite parties as PW1, DW1 and documentary evidence as Exts.A1 to A7 and B1 to B7.<br /> Issue Nos. 1 to 3<br /> Admittedly the complainant is insured under Pravasi Suraksha Kudumba Arogya Scheme introduced by the opposite party. Ext.A1 is the certificate of Insurance. As per Extr.A1 effective date is 3.9.99 and expiry date 2.9.04. Premium shown paid Rs.3490/- in Ext.A1.<br /> The complainant underwent two major operations. Ext.A6 lawyer notice sent by the complainant carries information regarding these operations. The complainant underwent second operation to his right eye from Dhanalakshmi Hospital, Kannur. The photocopy of the discharge summary card issued from the hospital and the bills were submitted to opposite party with the notice. Opposite party denied this. But these facts are seen written in Ext.A6. It is also seen written in Ext.A6that the complainant is ready to submit the original of the documents as and when so order. Moreover, Ext.A6 carries the list of enclosure of the above said documents summary card and bills. Thus Ext., A6 proves the opposite party has information with them that the insured complainant underwent two operations. It has also written that the original document was not produced together with the notice only because of the failure to consider the earlier claim in which all original documents had already been submitted to opposite parties.<br /> It is true that opposite parties considered the claim only after the notice Ext.A6. Opposite parties contents that they granted the claim on the receipt of the claim Form but not disclosed the date when they received it. Ext.B2 is the claim Form. It has shown the OP.No.78112 inpatient No.20039, date of admission to hospital 4.12.2001 and date of discharge 8.12.2001. Particulars of bill for a sum of Rs.5344/- is also shown under the head “Details of Treatment Expenses”. But Ext.B4 series medical bills 20 in number will show a total sum of Rs.8394.23. Ext.B2 proves that the 1st operation of the complainant underwent on December 2001 but opposite party entertained the claim only after 5.1.04 when the notice was received. No satisfactory explanation could be given by the opposite parties for such a long delay.<br /> The contention of opposite parties is that as per policy condition the insurer is not bound to pay any amount as compensation. Opposite parties admits the insurance but deny their liability to pay the amount claimed by the complainant since the treatment expenditures he had to incur was for diabetics. This contention is absolutely wrong and carries an unfair tune. If it is so the claim of the complainant should not have entertained at all. Herein the claim of the complainant considered partly and paid Rs.5, 344/- for the treatment the complainant undergone for surgery and opposite parties also admitted that the complainant is legally entitled for that amount. How does it possible if the above contention is true and correct. The question of diabetic does not arise at this juncture. Non-payment has been attempted to be justified by saying that the complainant is not entitled as per terms and conditions whereas the payment is been appreciated as legally entitled one. The case of the opposite parties is that they were notable to settle the claim for Rs.8000/- towards the treatment following second operation only because complainant had not submitted the claim form along with medical bills and certificates. <br /> The contention of opposite parties that there is no claim form for the second operation is not acceptable. Ext.A6 is a document which proved that the opposite parties are aware of the information with respect to operation and treatment. Opposite parties are legally bound to explain what prevent them from issuing claims form. What is the reply of Ext.A6? Can it be finished by part payment what are the steps that have been taken to keep the best interest of the insured. Whether it is neglected or prevented? The opposite party Insurance Company cannot keep mum towards these questions. Thus we are of the opinion that there is deficiency on the part of opposite parties The perusal of the bills dated 16.11.02 with respect to the second operation will show an expense of an amount of Rs.9971.41. The claim of the complainant Rs.19, 000/- is quite reasonable. The bill produced by opposite parties alone shows a total amount of Rs.8394.23 and the bill produced by the complainant on records shows a total amount of Rs.9971.41 which comes an aggregate total of Rs.18, 365.64. The opposite parties have paid only Rs.5, 344/-. The opposite parties are liable to pay the balance amount of Rs.13, 000/- with interest @8% from the date of notice ie.5.1.2004 till realisation of the amount. We are also of opinion that the complainant is entitled to get Rs.5000/- as compensation together with a sum of Rs.1000/- as cost of these proceedings. Hence the issues 1 to 3 are found in favour of the complainant and passed orders accordingly.<br /> In the result, the complaint is allowed directing the opposite parties to pay the complainant<br /> 1. A sum of Rs.13, 000/- (Rupees thirteen thousand only) with interest @8% from the <br /> Date of notice ie.5.1.2004 till date of realization of the amount.<br /> 2. a sum of Rs.5000/- (Rupees Five thousand only) as compensation and<br /> 3. A sum of Rs.1000/-(Rupees One thousand only) as cost.<br /> <br /> The amount shall be paid within one month from the date of receipt of this order, failing which the complainant is allowed to execute the order against the opposite parties.<br /> <br /> Sd/- Sd/- Sd/- <br /> President Member Member<br /> <br /> APPENDIX<br /> Exhibits for the complainant<br /> A1.Pravasi Suraksha Kudumba Arogya insurance certificate issued by Ops<br /> A2, Bill dt.16.11.02 issued from Dhanalakshmi Hospital,Kannur<br /> A3.Medical bills.<br /> A4.Discharge card issued from Dhanalakshmi Hospital, Kannur<br /> A5.Letter dt.1.3.04 sent by OP to complainant<br /> A6. Copy of the lawyer noitce dt.5.1.04 sent to OP<br /> A7.Postal receipt and acknowledgement card.<br /> Exhibits for the opposite parties<br /> B1.Pravasi Kudumba Arogya Scheme certificate issued to complainant<br /> B2.Claim form<br /> B3. Medical certificate<br /> B4.Medical bills<br /> B5.Copy of the confidential report application form sent to Dhanalakshmi Hospital Kannur dt.22.1.02.<br /> B6.Copy of the registered letter dt.1.3.04 sent to complainant<br /> B7.Copy of the lawyer notice issued to OP<br /> Witness examined for the complainant<br /> PW1.Complainant<br /> Witness examined for the opposite parties<br /> DW1.R.Suresh Babu<br /> /forwarded by order/<br /> <br /> Senior Superintendent<br /> <br /> <br /> Consumer Disputes Redressal Forum, Kannur<br /> <br />