THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM Present: Sri. Santhosh Kesavanath P., President Smt. Bindhu M. Thomas, Member Sri. K.N. Radhakrishnan, Member CC. No.293/2009 Friday, the 30th day of April, 2010 Petitioner : Michael Jacob, Elivalikara Mukkoottuthara P.O Kanjirappally. Vs. Opposite party : The Oriental Insurance Co. Ltd. Divisional Office, Kottayam Reptd. By its Divisional Manager. (By Adv. Sajan A. Varghese) O R D E R Sri. K.N. Radhakrishnan, Member The case of the complainant filed on 8..9..2009, is as follows: He had taken a Mediclaim Policy from the 1st opposite party under the Universal Health Insurance Scheme. While so on 24..6..2009 he had admitted in the Mary Queen Hospital, Kanjirappally due to injury in his right leg’s 1st finger. Due to heavy puss the complainant was admitted in the above Hospital. The complainant was afraid of that he was a diabetic patient and so the finger was suspected to be amputed. He requested the Hospital authorities for discharge on 26..6..2009 with an intention to get an expert examination and treatment in higher hospital. On 27..6..2009 he was admitted in the Amritha Institute for Medical Sciences as M.R.D 785223 for higher treatments. Due to the family problems and on request the Hospital authorities discharge the complainant and advise for wound cleaning in a local clinic and review after two weeks. On 11..7..2009 doctor examined the complainant and prescribed some medicines. From 28..6..2009 the complainant had treated and cleaning was done with the Madona -2- Hospital, Erumely. The blood circulation of the leg became very slow and hence the wound healed only after 20 days. Petitioner submitted a claim before opposite party with all relevant documents and bills issue from the treated Hospitals ie. Mary Queens Hospital, Amritha Hospital and Madona Hospital. But opposite party sanctioned only the bill issued by Mary Queens Hospital from 24..6..2009 to 26..6..2009 for an amount of Rs. 2120/-. According to the complainant he was entitled for the entire treatment expenses. The opposite party was liable to issue the entire treatment expenses of the complaint. Hence this complaint. The notice was served with the opposite party they appeared and filed their version contending as follows: The complaint was not maintainable either in law or on facts. He made a claim based on the policy issued by the opposite party. The claim was duly processed and it was intimated to the complainant that he is eligible for an amount of Rs. 2120/- being the amount spent by him towards the inpatient charges at Mary Queens Mission Hospital, Kanjirappally from 24..6..2009 to 26..6..2009 and a voucher was sent to him to be returned after signing for the payment of the amount due to him. The complainant who has received the voucher has so far not returned the same but has filed this complaint. As per policy they are on liable to pay for hospitalization expenses for medical/surgical treatment at any Nursing Home/ hospital in India as in patient . The bill produced by the complainant along with the claim form were considered in detail and there was only one bill dt: 26..6..2009, described as I.P discharge bill for Rs. 2,124/- for the in-patient treatment at hospital as per the terms and conditions of the policy and the same was sanctioned and intimated to the complainant. There was no deficiency in -3- service on the part of the opposite party. Hence this complaint may be dismissed with costs. The complainant examined as PW1 and documents produced by him was marked as Ext.s. A1 to A3. The opposite party filed proof affidavit. Heard both sides. We have gone through the complaint, version documents and evidence. The case of the complainant is that the opposite party has not settled the claim as per policy. According to him he was entitled the entire claim amount as per policy. The opposite party has taken a contention that the complainant was entitled only for the treatment expenses/ hospitalization expenses as an in patient under the policy. According to them they are liable to pay only sanctioned amount as per the terms and conditions of the policy. The argument of the complainant is that all the treatment expenses incurred by him was compensated by the opposite party as per the policy. As far as the complainant is concerned the non hospitalization for other two hospitals was on the request of the complainant due to the family problems. The argument put forward by the opposite party that the complainant was not treated as an in-patient in the other two hospitals. From the available documents and evidences in this case that the treatment of the complainant, in 3 different hospitals for the same ailment. Moreover the opposite party has not a case that the treatment of the complainants was false. The stand taken by the opposite party was not sustainable because the treatment was decided by the doctor in which the patient was admitted in the hospital for long period or advise him to review after some days depends upon the conditions of the patient. In this case the complainant was admitted in a hospital and treated there as an inpatient and the same amount was -4- sanctioned by the opposite party without any objection. According to the complainant he was referred to Amritha Institute for Medical Sciences for higher check-up and expert treatment. The opposite party has not disputed the expert treatment and checkup. From the available evidence it can be seen that the treatment of the complainant was for the same ailment in 3 different hospitals. So we are of the opinion that the complainant was entitled the treatment expenses in 3 different hospitals.. Hence we are of the opinion that the case of the complainant is to be allowed. In the result the complaint is allowed as follows: We direct the opposite party to pay the entire claim amount to the complainant, as per the bill produced by him, and pay Rs. 1000/- as compensation for in conveniences and pay Rs. 750/- as cost of these proceedings. The order shall be complied with within a period of one month from the date of receipt of a copy of this order. If the order is not complied within the stipulated time the amount will carry interest @ 9% per annum from the date of order till payment. Sri. K.N. Radhakrishnan, Member Sd/- Sri. Santhosh Kesavanath P. President Sd/- Smt. Bindhu M. Thomas, Member Sd/- APPENDIX Documents produced by complainant: Ext. A1: Policy Schedule. Ext. A2: Policy condition Ext. A3: Copy of discharge voucher for an amount of Rs. 2120/- Documents produced by Opposite party: Ext. B1: Copy of policy schedule Ext. B2series: Copy of bills and treatments. By Order, Senior Superintendent. amp/4cs
| | HONORABLE Bindhu M Thomas, Member | HONORABLE Santhosh Kesava Nath P, PRESIDENT | HONORABLE K.N Radhakrishnan, Member | | 
