KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION

VAZHUTHACAD, THIRUVANANTHPAUAM

APPEAL.159/03

JUDGMENT DATED: 18.12.2009

PRESENT

SRI.M.V.VISWANATHAN              : JUDICIAL MEMBER

1. Branch Manager,                         : APPELLANTS

    Oriental Insurance Co.Ltd.,

    Branch Office, Trio Chambers,

    Kanjikuzhy, Kottayam.

2. Divisional Manager,

    Oriental Insurance Co.Ltd.,

    Padinjarekkara Chambers,

    M.C.Road, Kottayam-1.

(By Adv.Saji Isac.K.J.)

                  vs.

Dr.K.J.Mathew, Kudakaseril,                     : RESPONDENT

Muttambalam.P.O., Kottayam.

JUDGMENT

SRI.M.V.VISWANATHAN    : JUDICIAL MEMBER

          The above appeal is preferred from the order dated 7^th January 2003 passed by CDRF, Kottayam in OP.No.784/99.  The complaint therein was filed by the respondent herein against the appellants/opposite parties alleging deficiency in service on their part in repudiating insurance claim putforward by the complainant under A1 medi claim policy.  The opposite parties entered appearance and filed written version and justified their action in repudiating  the medi claim policy.  They contended that hospital in which the complainant had undergone treatment for his illness was not having the required registration certificate issued from by the concerned local authority and that the said hospital was not well equipped as stated in clause 2.1(b) of the A1 policy. 

2. Before the forum below complainant was examined as PW1 and the  doctor from the hospital was examined as PW2.  Exts. A1 to A15 documents were also produced and marked  on the side of the complainant.  From the  side of the opposite parties,  DW2 Insurance Investigator and DW1, Officer of the opposite party Insurance Company were examined.  R1 to R10 series of documents were also produced and marked on the side of the opposite parties.  On an appreciation of the evidence on record, Forum below  passed the impugned order directing the opposite parties to allow the insurance claim made by the complainant with interest at the rate of 9% per annum from the date of the complaint till realization with cost of Rs.1000/-.  Aggrieved by the said order, the present appeal is  filed by the opposite parties therein.

          3. We heard both sides.   The learned counsel for the appellants/opposite parties submitted his arguments based on the grounds urged in the memorandum of the present appeal.  He canvassed for the position that hospital in which the complainant/insured undergone treatment was not registered and it was not a well equipped hospital as stipulated in policy conditions.  Thus, the appellants prayed for setting aside the impugned order passed by the forum below.  On the other hand, the learned counsel for the respondent/complainant supported  the impugned order passed by the forum below.  He much relied on oral testimony of PW2, doctor attached to the hospital and the documentary evidence adduced from the side of the complainant.  Thus, the respondent prayed for dismissal of the present appeal.

          4. The points that arise for consideration are:-

1)      Whether there was deficiency in service on the part of the appellants/opposite parties in repudiating the insurance claim made by the respondent/complainant under A1 medi claim policy?

2)      Whether the appellants/opposite parties have succeeded in establishing their contention that the hospital in which  the complainant undergone treatment was not a  registered hospital and it was not well equipped as stipulated  in the A1 policy conditions?

3)      Is there any unsustainable ground to interfere with the impugned order passed by  the Forum below?

5. Points 1 to 3:-

There is no dispute that the respondent/complainant was the holder of A1 medi claim policy issued by the opposite party/Oriental Insurance Co. Limited.  The respondent/complainant undergone ayurvedic treatment for the period  from 21.10.98 to 28.1.99.  Admittedly the complainant/insured undergone ayurvedic treatment for a total period of 100 days.  During the said period of treatment the respondent/complainant was having a valid mediclaim policy.  The complainant submitted claim for Rs.1,10,900/- towards the expenses incurred by him.  The treatment expenses  are covered by medical bills issued from the hospital where the complainant undergone  ayurvedic treatment as inpatient.  There is also no dispute  regarding the quantum of claim made by the complainant. 

6. The claim form submitted by the complainant/insured was repudiated by the insurance company on two grounds.  The 1^st ground is that the hospital where the complainant  had undergone treatment was not having the registration issued by the local authority.  It is to be noted that the  treatment was for the period from 21.10.98 to 28.1.99.    Ext.A8 is copy of the license issued by Aluva Municipality.  It is dated 23.2.2000 and it was for the year 1999-2000 ie.; for the period from 1.4.99 to 31.3.2000.  A8 license issued by Aluva Municipality  would show that  Dr.R.Raghavan was having a license to run an ayurveda hospital with 16 bed for the year 1999-2000.  There is no dispute that Dr.R.Raghavan is owner of the  hospital by name  International Foundation for Ayurvedic Research and Training.  The complainant/insured undergone the ayurvedic treatment  in the said International Foundation for Ayurvedic Research and Training.  Ext.A8 license would show that the said hospital was having the license only for the year 1999-2000 from 1.4.99 to 31.3.2000. It would further show that during the relevant period in which the complainant had undergone treatment in the aforesaid hospital was not having license issued by the local authority namely Aluva Municipality.  The complainant could not produce any other license or document to show that the said  hospital by  name International Foundation for Ayurvedic Research and Training was having license or registration issued by Aluva Municipality for the year 1998-99 or during the period from 21.10.98 to 28.1.99.  Thus, the materials available on record would justify the ground or contention adopted by the opposite parties that the said hospital was not having the registration or license during the relevant period ie from 21.10.98 to 28.1.99.

7. Ext.A15 is the conditions of  medi claim policy clause 2.1 of A15  policy conditions  has been incorporated by the Forum below  at para 8 of the impugned order.  Ext.A15 policy conditions would show that even if the hospital or nursing home  was not having the registration as stipulated under clause 2.1(a) but  was having the facilities under  clause 2.1(b)   is sufficient to treat the institution as Hospital/Nursing Home as defined under clause 2.1.  Then the  Insurance company is bound to honour the mediclaim.   2.1(b) stipulates that the hospital or nursing home (i) should have atleast 15 inpatient beds, (ii) fully equipped operation theatre of its own wherever surgical operations are  carried out (iii) fully qualified nursing staff under its employment round the clock (iv) fully qualified Doctors should be in charge round the clock.  It is to be noted that the hospital in which the complainant had undergone treatment  is ayurveda hospital.  So, there was no need for any  fully equipped  operation theatre for an ayurveda hospital. 

8. The evidence of PW2, the doctor attached to the hospital would show that the hospital was having 16 inpatient beds and the hospital was having fully qualified doctors and nursing staff.  Evidence of PW2 is strengthened by the documentary evidence  produced from  the side of the complainant.  The Forum below rightly considered the evidence available on record and held that the said hospital would comply with the                              stipulated conditions under clause 2.1(b) of A15 mediclaim insurance policy.  If that be so, the order passed by the Forum below directing  the opposite parties to honour the insurance claim can be as justified.  Appellants/ opposite parties cannot be justified in  repudiating the insurance claim putforward by the respondent/complainant(insured).  The finding of the Forum below that there was deficiency in service on the part of the opposite parties is to be upheld. There is no sustainable ground to interfere with the impugned order passed by the Forum below. The present appeal deserves dismissal.  These points are answered accordingly.

In the result the appeal is dismissed. The impugned order dated 7.1.2003 passed by CDRF, Kottayam in OP 784/99 is confirmed.  As far as the present appeal is concerned,  the parties are directed to suffer their respective costs.

SRI.M.V.VISWANATHAN              : JUDICIAL MEMBER

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