ORDER

By Smt.Padmini Sudheesh, President

          The case of  complainant is that the complainant is the policy holder of 1^st respondent and it was purchased through the 2^nd respondent which is a  broker  of 1^st respondent.  The complainant purchased the Individual Health Policy of 1^st respondent which has for one year medical expenses coverage by paying Rs.791/- and renewed the policy on 25/3/04 and thus  extended the policy coverage  upto 24/3/05.  The complainant is entitled to get all the medical expenses of her during the policy period.  The complainant had been admitted in Mother Hospital, Thrisur due to chest and abdominal pain on 4/2/04 and admitted there and for better treatment she was shifted to PVS hospital, Ernakulam on 20/2/04 and undergone an operation there and removed the Gall bladder and discharged on 25/2/04 and thereon she is under post hospital treatment.  The complainant already paid Rs.26,000/- towards medical expenses.  The complainant submitted her hospital bill along with the statement of medical expenses, discharge summary and medical report to the respondents but the respondents have failed to pay medical expenses.  So a lawyer notice was issued to the respondents on 18/2/05 and 1^st respondent sent a reply notice.  The delay caused in  solving the matter amounts to deficiency in service.  Hence the complaint.

          2. The counter averments of 1^st respondent are that this respondent admits that this respondent has issued an Individual Health policy in the name of complainant vide policy No.AHI-00001026 – 000 – 00 for a period from 25/3/03 to 24/3/04 and the total sum insured is Rs.50,000/-.  Since the claim is reported by the complainant it was referred to the TPA Paramount Health Service Pvt. Ltd. for processing the claim.  The complainant has not produced the necessary documents.  Hence the Paramount Health Service Pvt. Ltd. sent a deficiency letter on 7/4/04 to the complainant calling documents such as original discharge card of Mother hospital, PVS memorial hospital etc.  The complainant has not submitted the necessary documents or sent any reply.  So a reminder deficiency letter was sent by the Paramount Health Service Pvt. Ltd. dated 3/5/04 calling the documents stated in the  deficiency letter dated 7/4/04.  The complainant was called to submit the documents within 7 days.  The complainant has not responded to these letters also.  Reminders were sent on  20/5/04 and 22/6/04 calling the documents.  On 18/2/05 the complainant sent a lawyer notice to this respondent on 8/3/05.  This respondent sent a reply to the complainant counsel.  No deficiency in service is committed by this respondent.  The complainant has not submitted the necessary documents  for processing the claim.  This is the only reason for not processing the claim.  Since the complainant has not produced the documents the  admissibility of the scheme could not be considered.  By not submitting the documents insured has  breached the policy terms and conditions.  So the complainant is not entitled to get any amount from this respondent.  Hence dismiss.

          3. The counter of 2^nd respondent is that this respondent is totally an unnecessary party in this litigation.  This respondent acted only as a broker of 1^st respondent in purchasing  policy by complainant.  If the complainant is entitled to get the policy amount  1^st respondent will be liable to pay the same.  At the time of purchasing  the policy this respondent convinced the complainant everything about the policy.  The treatment expenses stated in the complaint are not correct.  It is denied that this respondent told the complainant that the amount will be got within two weeks.  No medical bills were entrusted with this respondent.  Hence dismiss.

          4. Points for consideration are:

1) Whether the complainant is entitled to get the amount claimed?

2) Other reliefs and costs?

          5. The evidence adduced consists of Exhibits P1 to P10 and R1 to R8.  2^nd respondent submitted no evidence and no oral evidence  adduced by complainant and 1^st respondent.

          6. The complaint is filed to get reimbursement of medical expenses incurred to complainant from 1^st respondent.  The complainant is the individual health policy holder of 1^st respondent and she was admitted in Mother hospital, Thrissur on 4/2/04 and discharged on 5/2/04.  She was also admitted at PVS hospital, Cochin on 22/2/04 and after the operation she was discharged on 25/2/04.  The complaint is filed to get Rs.26,000/-  in total towards hospitalization expenses post hospitalization expenses and pre hospitalization expenses.  According to the complainant as per the policy she is entitled to get  the above mentioned expenses.

          7. The 1^st respondent contended the case only on the reason that the  complainant has not produced necessary documents to process the claim even if letters were sent.  According to them  as soon as the claim is reported it was referred to Paramount Health Service Pvt. Ltd. for processing the claim.  But the complainant has not  produced  necessary documents.  So the 1^st respondent  stated that since no necessary documents were produced they were unable to process the claim.  So according to them there is no deficiency in service on their side.  The 1^st respondent produced Exhibits R1 to R8 documents in support of their claim.  Exhibit R2 is the copy of deficiency letter sent to complainant requesting documents.  Exhibit R3 is the copy of reminder deficiency letter sent to complainant  requesting the submission of some documents in order to process the claim.  So the complainant was liable to produce the documents demanded by the company to settle the claim.  This is not done by complainant.  Even if these letters were sent no reply  has been sent by complainant.  According to complainant the non payment of amount is a deficiency in service of 1^st respondent.  But the  submission of necessary documents to process the claim is the  duty of complainant and she was bound  to produce the same.  Exhibit P8 and Exhibit R1 are the policy copy  with terms and condition.  There is a condition stating the preexistence of disease.  Only if documents were produced by the complainant  it is to be looked into.  The complainant failed to co-operate with   the 1^st respondent company.  This act of the complainant is illegal  There is no deficiency in service on the part of 1^st respondent.

          8. In the result the complaint is dismissed and the complainant is directed to submit the documents demanded by the 1^st respondent company within a month from the date of receipt of copy of this order.  The 1^st respondent is directed to process the claim within a month after receiving the documents and if any dispute arises the complainant is at liberty to approach the Forum again.  No order as to cost and compensation.

          Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open Forum this the 7th   day of June2011.

                                                                             Sd/- 

                                                                   Padmini Sudheesh, President  

                                                                             Sd/-

                                                                   Rajani.P.S., Member

                                                                             Sd/- 

                                                                   M.S.Sasidharan, Member

                             Appendix

Complainant’s Exhibits

Ext. P1 Discharge bill

Ext. P2 Policy schedule

Ext. P3 Renewed policy schedule

Ext. P4 Histo Pathological report

Ext. P5 Discharge summary

Ext. P6 Echo Doppler report

Ext. P7 Ultrasound abdomen

Ext. P8 Policy terms and conditions

Ext. P9 Copy of lawyer notice

Ext.P10 Lr. dtd. 8/3/05

Respondent’s Exhibits

Ext. R1 Policy copy with terms and conditions

Ext. R2 Deficiency letter

Ext. R3 Reminder Deficiency letter

Ext. R4 Reminder Deficiency letter           

Ext. R5 Copy of lawyer notice

Ext. R6 Reply  letter dtd. 8/3/05

Ext. R7 Reply  letter dtd. 31/3/05

Ext. R8 Reply letter dtd. 22/4/05

                                                                                                Id/-

                                                                                         President