CONSUMER DISPUTES REDRESSAL FORUM
PALAKKAD, KERALA
Dated this the 26th day of April, 2012.
Present: Smt. Seena. H, President
: Smt. Preetha. G. Nair, Member
: Smt. Bhanumathi. A.K, Member Date of filing: 15/02/2012
CC / 36/ 2012
Sujatha.M, aged 44 years
W/o.Rajamanikkam,
Sreemathangi illam,
Chullimada, Kallimala, - Complainant
Kanikode P.O, Palakkad-678 621
(BY ADV. U.Suresh & K.Dhananjayan)
Vs
1. Cholamandalam General Insurance Co. Ltd.,
Regd Office,Hari Nivas Towers,
2nd Floor, 163 Thambuchetty Street,
Parrys Corner, Chennai 600001
Tamilnadu, Rep.by Managing Director/
Authorised Signatory.
2. Managing Director/Authorised Signatory,
Cholamandalam General Insurance Co. Ltd., - Opposite parties
Regd Office,Hari Nivas Towers,
2nd Floor, 163 Thambuchetty Street,
Parrys Corner, Chennai 600001
Tamilnadu.
O R D E R
BY SMT. BHANUMATHI. A.K, MEMBER
Facts of the case in brief:
The complainant had joined a medical insurance policy known as “Cholamandalam MS General Insurance” under the Group Health Master Policy in her name. The complainant had taken the said policy by remitting Rs.4,100/-(Rupees four thousand one hundred only). As per the terms and conditions and coverage of the policy the complainant, her spouse Rajamanikkam and her child Nirmalkumar.S.H are covered under the scheme and are also protected. The policy was taken on 19th June 2010 and the coverage of the policy was for a period of one year from 19th June 2010 to 18th June 2011.
As per the terms of the policy, the policy holder or beneficiaries are entitled for getting the total post hospitalization expenses, pre hospitalization expenses and day care expenses with the maximum limit of Rs.2 lakhs.
Being so the husband of the complainant had been admitted in K.G.Hospital, Coimbatore for an emergency operation due to a severe pain in the lumbasacral region on the left side. Because of these complaints as per the expert advice of Dr.M.Natarajan, Lumbar Radiculopathi had been performed on 2.2.2011 and discharged from the hospital on 7.2.2011. From 2.2.2011 to 07.02.2011 he had been treated as inpatient in the hospital. For the purpose the complainant had spent Rs.18,277/- (Rupees Eighteen thousand two hundred and seventy seven only). The complainant filed a claim petition to the opposite parties to reimburse of the medical expense. But the opposite party had repudiated the claim on the ground that the treatment given to the husband of the complainant does not warrant inpatient treatment. The opposite party also alleged that the complainant's husband had the history of this particular ailment and discectomy was made in 1982 itself, which is prior to the inception of the policy. But the patient has not chosen any treatment by his own choice or desire but has just obeyed the expert advice of expert doctor who has attended the patient at K.G.Hospital. As per the policy coverage and conditions the complainant is entitled to get refund of the medical expenses ie Rs.18,277/- (Rupees Eighteen thousand two hundred and seventy seven only) and consecutive total expenses as per her claim i.e Rs.26,500/- (Rupees Twenty six thousand five hundred only) from the opposite parties. As alleged by the opposite parties the complainant has not suppressed any material facts. The disease known as Lumbar Radiculopathy is not a disease subsisting from or for a longer period. So the complainant seeking an order directing the opposite parties to pay Rs.2,65,000/- (Rupees Two lakh sixty five thousand only) and Rs.10,000/-(Rupees Ten thousand only) as compensation for mental agony along with cost of the proceedings.
Opposite parties remained ex-parte.
Complainant filed affidavit and Exbt.A1 to A10 marked.
Matter heard.
Issues to be considered are:
1. Whether there is deficiency of service on the part of opposite parties?
2. If so, what is the relief and cost?
Issue No.1 &2
The complainant has joined and taken a medical insurance policy known as “Cholamandalam MS General Insurance” on 19th June 2010 by remitting Rs.4,100/-(Rupees Four thousand one hundred only) and the opposite parties have issued a certificate of insurance to the complainant vide No.560558053000003526 and also 0558053000003526. As per the terms of the policy, the complainant her spouse and child are covered under the scheme. The coverage of the policy was for a period of one year from 19th June 2010 to 18th June 2011. All these facts are revealed from Ext.A1 document. Within the period of policy coverage that is on 2.2.11 the complainant's husband has admitted in to KG Hospital, Coimbatore as per the expert medical advice and Lumbar Radiculopathy had been performed on 2.2.11 itself. He had been discharged from the KG Hospital on 7.2.2011. For this purpose the complainant had spent Rs.18,277/- (Rupees Eighteen thousand two hundred and seventy seven only) in KG Hospital as full and final bill. It is evident from the Ext.A7 document. Then after the complainant made a claim before the opposite parties to claim reimbursement medical expenses. But the opposite parties had repudiated the claim made by the complainant on the ground that the complainant's husband had the history of this particular ailment and Lumber discectomy was done in 1982 itself. But it has not proved by the opposite parties as they remained exparte. Hence the contention of the complainant stands unchallenged. In the claim form the complainant claimed an amount of Rs.26,500/- (Rupees Twenty six thousand five hundred only). But the complainant did not produce the documents for the amount except Ext.A7. So that the amount other than Rs.18,277/- (Rupees Eighteen thousand two hundred and seventy seven only) cannot be considered.
From the above discussions we are of the view that the opposite parties are deficient in repudiating the claim made by the complainant.
In the result complaint allowed opposite parties are jointly and severally directed to pay an amount of Rs.18,277/- (Rupees Eighteen thousand two hundred and seventy seven only) and Rs.2,000/-(Rupees two thousand only) as compensation and cost.
Order shall be complied within one month from the date of receipt of order, failing which the complainant is entitled for 9% interest per annum for the whole amount from the date of order till realization.
Pronounced in the open court on this the 26th day of April, 2012
Sd/-
Smt. Seena. H
President
Sd/-
Smt. Preetha.G.Nair
Member
Sd/-
Smt. Bhanumathi.A.K
Member
A P P E N D I X
Exhibits marked on the side of complainant
Ext. A1– Photocopy of the certificate of insurance dt.19/06/2010 issued to the complainant by the opposite party.
Ext. A2 – Photocopy of discharge summary dt.07/02/2011 issued from KG Hospital, Coimbatore.
Ext. A3 – Photocopy of short discharge notes dt.07/02/2011 issued from KG Hospital,Coimbatore.
Ext.A4– Photocopy of the laboratory report dt.03/02/2011 issued from KG Hospital,Coimbatore.
Ext.A5– Photocopy of the laboratory report dt.02/02/2011 issued from KG Hospital,Coimbatore.
Ext.A6 – Photocopy of the laboratory report dt.02/02/2011 issued from KG Hospital,Coimbatore.
Ext.A7– Photocopy of the inpatient receipt dt.07/02/2011 issued in the name of Rajamanikkam to the complainant from KG Hospital,Coimbatore for Rs.18,277/-.
Ext.A8– Photocopy of the pre-authorization request form filed by the complainant.
Ext.A9– Copy of the lawyer notice sent by the complainant to the opposite party.
Ext.A10– Photo copy of the repudiation letter sent by the opposite party to the complainant.
Exhibits marked on the side of opposite party
Nil.
Witness examined on the side of complainant
Nil.
Witness examined on the side of opposite party
Nil
Cost allowed
Rs. 2,000/- (Rupees Two thousand only) allowed as cost of the proceedings.
