CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM Present Sri. Santhosh Kesavanath P. President Smt. Bindhu M. Thomas, Member K.N. Radhakrishnan, Member CC No. 186/2008 Saturday, the 30th day of October , 2010 Petitioner : Vinodkumar C.R Chembolamadathil House, Vadavathoor P.O Kottayam. (By Adv. Anish Ramakrishnan) Vs. Opposite party : 1) National Insurance Company, (Deleted) Civil Station Branch, Kottayam -2. reptd by its Branch Manager. (The 1st opposite party is deleted as per I.A order 188/08 Dtd: 12.3.09 of President CDRF, Kottayam) 2) The Plant Human Resource Manager, M.R.F Ltd., Vadavathoor P.O Kottayam. 3) New India Insurance Company, Civil Station Branch, reptd. by its Branch Manager, Kottayam. O R D E R Sri. Santhosh Kesavanath P., President. Case of the petitioner filed on 23..7..2010, is as follows. Petitioner is an employee of the first opposite party. First opposite party insured the petitioner along with other employees under the Group Medi Claim Insurance Scheme. Petitioner paid Rs. 2,841/- as premium, for the policy to the insurance company through the second opposite party. According to the petitioner as per the policy condition petitioner is entitled to get full expenses of medi-claim -2- treatment. On 6..9..2007 petitioner was admitted in Sukhodaya Ayurved Hospital and he discharged on 21..9..2007. Again the petitioner admitted in the same hospital on 14..10..2007 and discharged on 19..10..2007. Petitioner had under gone Ayurvedic Panchakarma treatment . The total bill of the treatment and medicine is for Rs. 34792/-. Treatment expenses were paid by the second opposite party in advance. Later the second opposite party informed the petitioner that second opposite party had only get Rs. 14,000/- from first opposite party. Moreover on 1..7..2008 second counter petitioner demanded advance amount of Rs. 20,792/- from the petitioner. According to the petitioner second opposite party is liable to pay the entire claim amount of Rs. 34,792/-. Petitioner states that act of the opposite party in non refund of the claim amount of the petitioner amounts to deficiency in service. So, petitioner prays for a direction to the opposite party to pay balance claim amount of Rs. 20,792/-Petitioner also clams cost and compensation. Notice was issued to the opposite party second opposite party has not filed any version so second opposite party was set ex-parte. First opposite party filed version contenting that petition is not maintainable. According to the first opposite party liability of the insurance company is only as per the terms and conditions of the policy. Petitioner was not under went treatment in a ‘hospital’ as defined in the policy. The bill produced by the petitioner for the period of treatment are highly exorbitant, arbitrary and baseless. There is no scientific support for the said treatment. Since the claims of the petitioner is suspicious it is -3- not allowable. The amount already paid was after getting an expert opinion of a qualified Ayurveda doctor. The petitioner has not submitted the bills for an amount of Rs. 34,792/- So, the opposite party prays for dismissal of the petition with their costs. Points for determinations are: i) Whether there is deficiency in service on the part of the opposite party? ii) Relief and costs? Evidence in this case consists of affidavit filed by both parties and Ext. A1 and A2 documents on the side of the petitioner and Ext. B1 to B3 documents on the side of the opposite parties . Point No. 1 Admittedly an amount of Rs. 14,000/- was issued to the petitioner. Claim of the petitioner is for Rs. 34,792/- petitioner produced Ext. A1 and A2 bill to prove that claim of the petitioner is Rs. 34,792/-. Opposite party denied full payment of the claim of the petitioner on the ground that petitioner has not under went treatment in a hospital as defined in the policy. In our view by paying an amount of Rs. 14,000/-. Opposite party admits that the treatment in the hospital underwent by the petitioner will come under the policy. Even though the opposite party has a definite case that the bills produced by the petitioner are exorbitant unscientific and baseless . Opposite party has not adduced any evidence to prove their allegations. In our view the act of the opposite party in repudiating a part of -4- the claim of the petitioner is a clear deficiency in service. So, point No. 1 is found accordingly. Point No. 2 In view of the finding in point No. 1, petition is allowed and the petitioner is entitled for relief sought for . In the result the first opposite party is ordered to pay the balance claim amount of Rs. 20,792/- to the second opposite party. If the 2nd opposite party had received the said amount from the petitioner Opposite party 3 shall pay the claim amount to the petitioner. Opposite party is ordered to pay an amount of Rs. 1,000/- as compensation for the loss and sufferings Rs. 1,000/- is ordered as cost of the proceedings. Opposite party is ordered to pay the cost and compensation to the petitioner. The order shall be complied with within one month of the receipt of this order. If the order is not complied as stated above the award amount will carry 9% interest from the date of filing of the petition till realization. Dictated by me transcribed by the Confidential Assistant corrected by me and pronounced in the Open Forum on this the 30th day of October, 2010. Sri. Santhosh Kesavanath P. President Sd/-- Smt. Bindhu M. Thomas, Member Sd/- Sri. K.N Radhakrishnan, Member Sd/- APPENDIX Document for the Petitioner Ext. A1: Copy of the bill Dtd: 21..9..2007 Ext. A2: Copy of bill Dtd: 19..10..2007 Documents for the Opposite party Ext. B1: Condition of the policy Ext. B2: Opinion of Dr. Ravishankar. Ext. B3: Receipt issued by P.H.R Manager, M.R.F By Order, Senior Superintendent Received on / Despatched on amp/. 5cs
| | [HONORABLE Bindhu M Thomas] Member[HONORABLE Santhosh Kesava Nath P] PRESIDENT[HONORABLE K.N Radhakrishnan] Member | | 
