CONSUMER DISPUTES REDRESSAL FORUM,PALAKKAD

Dated this the 29^th April, 2016

PRESENT :  SMT. SHINY.P.R, PRESIDENT

               : SMT. SUMA. K.P, MEMBER  

               : SRI. V.P.ANANTHA NARAYANAN, MEMBER

Date  of filing : 9/07/2015

CC /100/2015

Sakthivel.S

S/o.Sivajanam,

Koundankalam,  Thekkedesam Village,

Chittur Taluk, Palakkad  District,

Kerala. Pin:  678 553                                               :        Complainant

(By Adv.P.Mohandas)       

             Vs

1. Authorized signatory United India Insurance

    Company Limited,  D.O-IV,                                  :        Opposite parties

   7^th Floor, United India Towers,

   Basheer Bagh Hydrabad- 5000029

2. Authorized signatory Good Health TPA Services,

    Plot  No.49, Nagarjuna Hills Panyagutta,

    Hydrabad, Andhra Pradesh 500029

    (Exparte)

3. Syamala Sunder, Manager,

    Andhra Bank, Kanjikode Branch,

    Chedayan kalai, Kanjikode West,

    Palakkad District, Kerla-678 623

   (By Adv.P.P.Gopalakrishnan)

O R D E R

By Smt. Suma. K.P, Member,

The complainant is holding a Savings Bank Account with 3^rd opposite party and as per the advice of the 3^rd opposite party the complainant took a membership of Good Health Plan Ltd. Hyderabad Branch office.  Complainant received insurance proposal from the 1^st opposite party for a sum of insured amount of Rs.1,00,000/- and paid insurance premium up to 08/06/2015 and received a  mediclaim policy No.050400/48/13/41/00000429.  Due to severe chest pain he was admitted in Lakshmi Hospital Palakkad on 05/09/2014 and discharged on 10/09/2014.  He had incurred hospital treatment expenses of Rs.1,02,000/- and he had borrowed it from friends and relatives.  On 10^th September 2014 he met the 3^rd opposite party and applied in the prescribed mediclaim form of the 2^nd opposite party Good Health Plan TPA services, Hyderabad Branch Office.  The 2^nd opposite party received the mediclaim application for hospitalization claim amount.  The complainant alleges that he had send all the original consultation papers invoice originals, original investigation reports and original discharge summary details and blank cheque through the 3^rd opposite party within 15 days.  On 6^th October 2014,  the website of the 2^nd opposite party shows that his hospitalization mediclaim amount application is approved for Rs.97,842/.  Now the complainant is undergoing treatment as an out patient and he had to spend Rs.2,000/- per month for the medicines. The complainant had not received the approved amount from the 1^st and 2^nd opposite parties.  Hence on 10/04/2015 he issued a lawyer notice to the 1^st opposite party but no reply was received from them.  The complainant submits that his family had financially suffered much due to the above attitude of the opposite parties.  Hence he had also claimed Rs.2,50,000/- as compensation for the mental agony and financial loss for the non payment of mediclaim hospitalization claim amount already approved on 6/10/2014.  The opposite party had committed deficiency in service by not paying the approved amount and by purposely denying the payment of the mediclaim already approved by the 2^nd opposite party through his savings bank account in the 3^rd opposite party branch.  The complainant alleges that the 3^rd opposite party had sent all the original documents through professional courier service.  Hence the complainant had approached before this forum seeking an order to allow his claim amount already approved by the 2^nd opposite party in the website on 6/10/2014 with interest @12% p.a. and compensation of 2,50,000/- for the deficiency of service by the act of 1^st opposite party along with cost.

Notice was issued to the opposite parties for appearance. 1^st and 3^rd  opposite parties entered appearance and filed their respective versions.  2^nd opposite party remained absent.  Hence he was set exparte.  

The 1^st opposite party contented that the complainant has not fully forwarded the details requested by the 2^nd and 1^st Opposite party and that is why this claim was not settled.  The limit of liability as per the policy issued is Rs.2lakh.  The claim as far as the company is concerned is pending for production of documents.  To settle the claim the following documents are mandatory for the 1^st and 2^nd opposite party. They are:-

1. Complete duly filled original discharge summary as the one submitted by the complainant is Xerox and incomplete.
2. Original angiogram report and angioplasty report supporting diagnosis
3. Stent invoice sticker/label
4. Indoor case sheet copy

Inspite of repeated requests made by the 1^st and 2^nd opposite party complainant had not forwarded the same.  Since the complainant had failed in supplying the documents requested, the company was not able to settle his claim and on receiving the particulars the company will be settling the claim.   The 1^st and 2^nd opposite party has not repudiated the claim.  There is no deficiency of service on the part of the insurance company or the 3^rd party agency,  The 1^st opposite party has no liability to pay 2.5 lakhs or any amount as damages to the complainant.  There  is no fault on the side of the 1^st and 2^nd opposite party in paying the insurance amount as per the terms and conditions in the policy.   Settlement of the claim  is not made because of the non co-operation of the complainant in producing the documents required by the opposite parties. Hence the above complaint has to be dismissed.

The 3^rd opposite party filed versions stating that he is unnecessary party to the proceedings and has nothing to do with the reliefs claimed in the complaint.  He admits that the complainant is holding a savings bank account with 3^rd opposite party.  The 3^rd opposite party had only facilitated and assisted the complainant to get a mediclaim policy and has nothing to do with the settlements of the claims.  The mediclaims if any have to be settled by the insurance company and the bank is not involved in any way in settling mediclaims.  Since no reliefs is claimed against the 3^rd opposite party the complaint against the 3^rd opposite party had to be dismissed.

Complainant filed the chief affidavit along with documents. 1^st opposite party had also filed proof affidavit. Ext.A1-A7 was marked from the part of the complainant.  Evidence was closed and the matter was heard.

The following issues are to be considered.

1. Whether there is any deficiency of service on the part of the opposite parties?
2. If so, what are the reliefs and cost? 

 ISSUES 1 & 2

We had perused the documents as well as affidavit produced before the forum. The complainant  had stated  in the chief affidavit that the 3^rd opposite party had sent all the original documents through professional courier services.  The receipt from the professional courier service are also produced along with the affidavit. The 1^st opposite party had stated in their affidavit that the original document has not been forwarded to them.  The complainant has not forwarded the original sticker of the stud used in his operation and other relevant documents.  The complainant had stated in the proof affidavit that he had send all the original documents through 3^rd opposite party and the 1^st opposite party submits that the one submitted by the complainant is xerox and incomplete.  According to the 1^st opposite party the original discharge summary along with original angiogram report  and angioplasty report supporting diaganosis, stend invoice sticker/label and indoor case sheet copy are mandatory for the settlement of the claim.  Inspite of repeated request complainant had not forwarded the same.  In the above circumstances we cannot attribute deficiency of service on the part of opposite parties.

However we direct the complainant to produce all the necessary documents demanded by the 2^nd opposite party  for the settlement of the claim as early as possible before the 1^st and 2^nd opposite party.  The 1^st and 2^nd opposite party  shall settle the claim within one month of receipt of those documents.

Complaint is partly allowed with the above direction.

Pronounced in the open court on this the 29^th  day of April, 2016.

                                                                   Sd/-

                                                                    Shiny.P.R

                                                                     President

                                                                       Sd/-                                                                                                                     Suma. K.P

                                                                     Member

                                                                               Sd/-

                                                          V.P. Anantha Narayanan

                                                                   Member

A P P E N D I X

Exhibits marked on the side of complainant

Ext.A1 –Copy taken from the web site of Good Health TPA services in the name of the complainant.

Ext.A2 series- Copy of lawyer notice dtd.10/04/2015 send to the 1^st opposite party  along with original postal receipt and ack.card.

Ext.A3- Original receipt from the professional courier service dtd.26/09/2014

Ext-A4- Photocopy of medical certificate from Lakshmi hospital for applying  financial assistance for treatment  dtd.09/10/2014

Ext.A5- Original receipt from the professional courier service dtd.28/10/2014

Ext.A6-Daily delivery sheet received from the courier service

Ext.A7-Daily delivery sheet received from the courier service

Witness marked on the side of complainant

Nil

Exhibits marked on the side of opposite party

Nil

Witness examined on the side of opposite party

Nil

Cost Allowed

No cost allowed.