IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Preethakumari: Member Smt.M.D.Jessy: Member Dated this, the 18th day of March 2010 C.C.No.161/2004 Kasamkattil Baby Thomas, “Kasamkattil House” P.O.Keezhpally, Kannur Dist. (Rep. by Adv.John Joseph) Complainant The Divisional Manager, M/s.Oriental Insurance Co., Divisional Office, South Bazar, Kannur 2. (Rep. by Adv.K.C.Santhoshkumar) Opposite party O R D E R Sri.K.Gopalan, President This is a complaint filed under section 12 of consumer protection act for an order directing the opposite party to pay a sum of Rs.10, 820/- with interest from 18.10.03 till realisation and an amount of Rs.1000/- as compensation together with the cost of these proceedings. The fact of the case in brief is as follows: The complainant took mediclaim policy. On 6.9.03 complainant suffered injury on the lumpar region and his left knee joint was dislocated due to an accident fall. He was admitted in Elje Aryavaidyasla and Nursing Home, Ulikkal on 12.9.03 and undergone treatment as an inpatient till 8.10.03. Complainant was discharged with an advice to continue medicine for two months. Complainant preferred claim along with supporting documents on 18.10.03 to opposite party through their agent. After about 3 months TTK Health Care sent a letter requesting to forward a copy of the policy in the current year 2003. Since the case of the complainant was confined to the policy taken in the year 2003. Complainant did not sent the policy of the current year and the same informed to the said agent over Telephone. Since there was no response Lawyer notice was sent on 8.3.04 calling upon to settle the claim. Opposite party sent a reply dt.12.3.04 stating that the complainant’s case is taken up before the Regional office, Kochi and request to wait for some more time. There after there is no response from the side of the opposite party and hence his complaint. In pursuance of the notice opposite party entered appearance and filed version in the form of counter denying the material averments and allegations. The contentions of the opposite party in brief are as follows; the complainant is the holder of Medi claim policy issued by the opposite party in the year 2003. He is entitled to get reimbursement from the opposite party in respect of the medical expenses incurred by him during the said policy period. The averment of the complainant that on 6.9.03 the complainant suffered injury on Lumbar Region and on his left knee joint was dislocated due to an accident fall and subsequently he was admitted in Elje Aryavydasala & Nursing home, Ulikkal and treated there etc. are not correct. The averment that he has preferred a duly filled up claim form along with supporting documents on 18.10.03 is also not correct. The complainant’s case is taken up before Regional office, Cochin is true. As per terms of policy issued to the complainant by the opposite party. Ayurvedic treatment is covered when hospitalized in Govt. Hospital or semi Govt. Hospitals only. The opposite party has aware of the claim only when he received lawyer notice dt.8.3.04. Same day opposite party sent a reply to bear with some more time to verify the matter with M/s.TTK Healthcare Services. On verification it is found that, the Ayurvedic treatment availed by the complainant is against terms and conditions of policy and thus opposite party is help less to allow the claim. This fact was informed to complainant by TTK Health Care Service by letter dt.27.7.04.there is no deficiency on the part of opposite party and hence to dismiss the complaint. On the above pleadings the following issues have been taken for consideration. 1. Wheher there is any deficiency in service on the part of opposite party? 2. Whether the complainant is entitled for the relief as prayed in the complaint? 3. Relief and cost. The evidence consists of the oral testimony of PW1, DW1, and Exts.A1 to A12 and B1 to B5. Issue Nos.1 to 3 Admittedly complainant is the holder of medi claim policy issued by the opposite party in the year 2003. The opposite party admitted in their version that the complainant is entitled to get reimbursement from the opposite party in respect of the medical expenses incurred by him during the said policy period. The case of the opposite party is that since it is Ayurvedic treatment availed by the complaint they are helpless to allow the claim since it is against terms and conditions on the reason that the Hospital from where he was treated was not either a Govt. Hopspital or a semi govt. Hospital. As per terms and conditions Ayurvedic treatment is covered when hospitalized in Govt. Hospital or semi Govt. Hospitals only. Complainant’s case on the other hand is that the opposite party is bound to reimburse the treatment expenditure of the complainant and there is no legally sustainable reason to deny the claim of the complainant. The central point of discussion is whether the Ayurvedic treatment in private Hospital will come within the coverage or not. If the claim is allowable for such treatment in private hospitals the complaint is entitled for the claim and the repudiation of claim shall be amount to deficiency in service. Complainant has not produced the policy schedule of the relevant period from 25.5.03 to 24.5.04. What prevented complainant from producing the policy schedule is not clear. Complaint hasn’t given a convincing explanation for non production of policy of the relevant period. Opposite party has produced ext. B1, the true copy of the policy schedule for the period from 25.503 to 24.5.04. Original is with the complainant. It is pertinent to note that complainant is not taking the policy first time. He is aware of policy schedule He has not so far made any complaint to opposite party that the policy schedule has not been issued to him for the period 25.5.03 to24.5.04. Under such circumstances the true copy produced by opposite party cannot be ignored on technical aspect. Complainant can very well prove or disprove the same by merely producing the original policy schedule. Ext.B1 the true copy of the policies schedule bears the seal that “Ayurvedic treatment is covered when hospitalized in Govt. or Semi Govt. Hospitals only”. The suppressing of document on the part of complanant is intended to hide the seal on the document by the Forum. The non production of the material document on the part of complainant weakened his case hitting the root of the merit whereby complainant failed to establish the deficiency in service on the part of complainant. Complainant is the custodian of the original document policy scheme. Mere production of this relevant document is large and sufficient to determine the case. If there is no such seal on the original Forum could be convinced that no such condition imposed preventing from getting the claim. Since the complainant is the custodian of document, the burden of proof is on the shoulders of complainant to produce the document and to prove that the policy scheudle issued to complainant hasn’t contained the abvoe noted seal that prevented the claim. It is pertinent to note that when the complaint was requested to forward a copy of the policy in the current year his answer was that since the claim of the complainant was confined to the policy taken in the year 2003, complainant did not send the policy of the current year and the said fact was informed to the said agent over phone. That means complainant did not forward the policy not because he is not having policy but the claim confined to the policy taken in the year 2003. Here the question is what is the policy relevant to be considered for the claim. Whatever it may be there is no pleading in respect of non receipt of policy. Date of accident is 5/9/03. The policy issued for the period from25.5.03 to24.5.04 which bear the office code 442500 and policy number 192 in the year 2004 is the relevant policy which has not be considered for the settlement of claims since the accident took place on 5.9.03. Complainant has not produced the relevant policy. The policy schedule produced and depended by the complaint is Ext.A12 which bear the policy number 769 for the period from 25.2.02 to24.5.03. Accident took place after the expiry of the policy 769, which has the cover note date 25.5.02. This is the previous policy not applicable as basic document to the relevant period for the purpose of the settlement of this claim. Hence the non production of policy schedule cannot be justified as it is a document, mear production of which is capable of removing entire doubt regarding the exclusion clause and other restrictions. Under such circumstances Ext.B1 cannot be ignored on the technical aspect. Pleading, proof affidavit and also deposition in cross examination opposite party shows that he has consistent case that Ayurvedic treatment is covered when hospitalized in Govt. Hospitals or semi govt. Hospitals only and the said clause is enclosed on the fact of the policy itself. Policy is issued to complainant. Complainant cannot say that complainant has no policy schedule for the relevant period. That was produced neither before the insurance company nor before the Forum. DW1 was not cross examined on the aspect with respect to the issuance of policy schedule. Hence the evidence adduced by the complainant by way of chief affidavit and the answers given in the cross examination proves that there was such clause on the face of the policy itself. Ext.B1, the true copy of the policy schedule though objected corroborating the evidence given by the opposite party. Considering the facts and circumstances of the case we are of opinion that complainant failed to establish his case. Opposite party cannot be blamed for repudiating the claim. If there is no seal as mentioned above, complainant can very well prove the same by production of policy schedule No.192 alone. The case clearly supports the contention of opposite party. Thus we answered issues 1 to 3 against complainant. In the result, complaint is dismissed. No order as to costs Sd/- Sd/- Sd/- President Member Member APPENDIX Exhibits for the complainant A1 & A2..Copy of the prescription issued by Dr.A.J.John A3& 4..Medical certificate given by Dr.A.J.John. A5.Bills issued by Elje Aryavaidyasala & Nursing Home. A6to A8.Copy of the lawyer notice AD and reply notice. A9.letter issued by M/s.TTK Health care service to the complainant A10 & 11.Policy and Brochure issued by OP A12.Policy schedule Exhibits for the opposite party B1.Policy schedule B2.copy of the reply notice dt.18.3.04 sent to complainant B3. copy of the letter dt.18.3.04 sent to complainant B4.Copy of the letter sent by M/s.TTK Health care Ltd. To the complainant B5.claim form Witness examined for the complainant PW1.Complainant PW2.Mathew Joseph Witness examined for the opposite party DW1.K.Sreedharan /forwarded by order/ Senior Superintendent Consumer Disputes Redressal Froum, Kannur.
| | [HONORABLE PREETHAKUMARI.K.P] Member[HONORABLE MR. GOPALAN.K] PRESIDENT[HONORABLE JESSY.M.D] Member | | 
