SRI. JIMMY KORAH (PRESIDENT)

The case of the complainant is that she was insured her mother under mediclaim insurance policy of the opposite parties as a dependent. She was admitted in Amrita Institute of Medical Science, Emakulam and thereafter she was treated in K.V.M. Hospital, Cherthala.   After the treatment complainant preferred  a claim before the opposite parties. But opposite parties repudiated the claim of the complainant.  Hence she filed this complaint alleging deficiency of service against the opposite parties.

2.  Opposite parties filed version stating that there is valid insurance policy in the relevant period.   The complainant has preferred a claim claiming Rs.l ,51,588/-.  But she was not submitted the original of the bills and documents. Thereafter insurance company sends a letter demanding the original bill. But she was not submitted the same. Hence they were repudiated the claim. So there is no deficiency .of service on the part of the opposite parties.

3.  Considering the rival contentions of the complainant and opposite parties, this Forum raised following issues:-

            Whether the complainant is entitled for compensation from the opposite parties establishing the deficiency as averred in the complaint?

4.  Complainant  given evidence  and  produced  4  documents.      These  documents    were  marked as Exts. A1  to A 4 series.  These  documents  were   marked  subject  to objection and proof.   The medical bills were Xerox copies.   Opposite parties  given evidence and produced 6 documents which were marked as Exts. B 1 to B6.

5.  We are gone through the entire evidence (both  oral and documentary) of this case in detail. There is no dispute with regard to policy coverage and treatment. The only dispute is with regard to original bill given by the hospital authorities is necessary for processing the claim. It is well settled that no one can get double benefit for  the same cause.  The case of the complainant is that the original of the bills were lost from their custody.  The opposite party argued that the original of the bills may be submitted before other authorities for getting medical reimbursement or· mediclaims.  As per the terms and conditions of the insurance policy, clause 6-3 it is specifically stated that " The insured shall obtain and furnish the TPA  all original bills and other documents upon which claim is based and also additional information or assistance as the company may require in dealing with the claim."   Insurance is a contract between two parties and the terms and conditions will  govern  the  essence  and spirit of the contract.   In this case it is specifically stated that

original bills of the treatment shall be necessary for the process of claim.  The word used is shall. So the original bill is mandatory for processing the claim.  The insurance company has given a specific letter demanding the original bills.  In the complaint, complainant has stated that immediately after admission in the hospital she approached the 3^rd opposite party to get an advice from  them to lodge the claim after discharge.  But in the affidavit submitted by the complainant to the opposite party ( Ext. B5), it is stated that mother's condition had been very critical and no thought had been given to preserving the bills for filing for mediclaim reimbursement and was lost. These statements are contradictory.  The complainant has also filed an interim application for directing the opposite parties to produce the original bills and documents.  From the documents and from the statements it can be brought out that complainant is very well aware that original bills are necessary for processing the claim. Further complainant filed vexatious petition for taking adverse inference against the opposite parties after filing an affidavit stating that it was lost.  From these petitions it can be seen that complainant approached this Forum with fraudulent intention.  Hence we are of the opinion that there is no deficiency of service on the part of the opposite parties.  

In the result,  complaint dismissed. No order on cost.

Pronounced in open Forum on this the 27^th day of  February, 2009.

                                                                                    Sd/- Sri. Jimmy Korah:

                                                                                    Sd/- Sri. K. Anirudhan:

                                                                                    Sd/- Smt. N. Shajitha Beevi:

Appendix:-

Evidence of the complainant:-

PW1                -           Sheela Vinod (Witness)

PW2                -           Sasidharan (Witness)

Ext.A1             -           Advocate notice dated dated 5.10.2005

Ext.A2             -           Letter dated 2.1.2006 (Photo copy)

Ext.A3 (1 & 2) -           Discharge Summary of KV.M. Hospital dated 10.5.04, 23.6.04

                                                (Photo copy)   

Ext.A3 (3 to 6) -          Medical bills  from Amritha Hospital     

Ext.A4(1)         -           Bill for Rs.16375/-

Ext.A4(2)         -           Bill for Rs.11260/-

Ext.A4 (3 to 6)-           Discharge Summary of Amritha Hospital (Photo copy)

Evidence of the opposite parties:-         

RW1                -           Preetha S. (Witness)

Ext.B1              -           Policy Schedule

Ext.B2              -           Terms and conditions of the Cancomfort Mediclaim insurance policy   

                                    (Photo copy)

Ext.B3              -           Claim Form (Photo copy)

Ext.B4              -           Letter to the 3^rd opposite party from  the complainant (Photo copy)

Ext.B5              -           Assurance given by the complainant for producing the original bills

Ext.B6              -           Letter to the 3^rd opposite party from the complainant (Photo copy)

// True Copy //

                                                                                      By Order

                                                                                                Senior Superintendent

To

            Complainant/Opposite parties/S.F.       

Typed by:- pr/-

Compared by:-