IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Saturday the 31st day of December, 2011
Filed on 11.05.2011
Present
- Sri. Jimmy Korah (President)
- Sri. K. Anirudhan (Member)
- Smt. N. Shajitha Beevi (Member)
in
C.C.No.165/2011
Between
Complainant:- Opposite parties:-
Sri. George V.J. 1. The General Manager, TTK Health
Bose Nivas, Chunakkara Naduvil Care Pvt. Ltd., 1400-B, Mareena
P.O. Chunakkara, Mavelikara Taluk Buildings, M.C. Road, Eranakulam
Alappuzha Dt. – 690 534 Cochin – 682 016
(By Adv.T.P. Satheesan)
2. The Divisional Manager
M/s. National Insurance Co. Ltd.
Divisional Office, Urumbath Building
Pump Junction, Aluva
(By Adv. C. Muraleedharan)
O R D E R
SRI. K .ANIRUDHAN (MEMBER)
Sri. George has filed this complaint before the Forum on 11.5.2011, alleging deficiency in service on the side of the opposite parties. The allegations of the complainant are as follows:- He had obtained a Policy from the opposite parties for the Medi-claim vide No.571000/46/10/ 8500000004, TTK ID card No. KOC-NC-10152-000-000-1590 A dt. of valid 1.4.2007. The opposite parties are jointly acted as third party administrative service for Medi-claim Policy settlement agency. He had undergone medical treatment in the Travancore Medical College at Umayanalloor for Liver problems from 16.12.2010 to 4.1.2011 by impatient and the treatment was done by Dr.Ananthakrishnan. After the treatment he had contacted the first opposite party with all the required documents obtained from the said Hospital for getting the Medi-claim amount including the Medical Certificate from the said Doctor of the Hospital. The claim amount is only Rs.31,117/- and it includes all the expenses incurred by him for the said treatment On 18.12.2010, the first opposite party had approved a sum of Rs.15000/- towards the authorized limit for the treatment. But on 4.1.2011, the first opposite party had intimated him regarding cancellation of the above amount for the reason of Alcoholic Liver disease. But the certificate issued by the said doctor had stated that the Liver cirrhosis disease cannot be treated that Alcoholic Liver disease. So the cancellation of the Medi-claim by the opposite parties are highly illegal and arbitrary. Earlier, he had obtained treatment for Liver complaint from VSM Hospital at Mavelikara and Pushpagiri Medical College at Thiruvalla. The doctor of the said Hospital had diagnosed that the complainant was chronic Liver disease and it cannot be treated that the disease was not Alcoholic Liver disease. The opposite parties are jointly and severally liable to give proper relief to him. So the opposite parties are not liable to repudiate the claim. By way of rejecting the claim, the opposite parties had committed deficiency in service and it was only to harass him, and committed dereliction of duty. He had sent Advocate notice to the opposite parties. But he had not obtained any relief. Hence, this complaint for proper relief.
2. Notices were issued to the parties. First opposite party was absent. Considering the absence of the first opposite party, they were set exparte by this Forum. 2nd opposite party entered appearance and filed detailed version.
3. In the version, 2nd opposite party had stated that there is no deficiency in service on their part and stated that they have duly entertained, perused and analyzed all the records and certificates and repudiated the claim on the basis of policy conditions on justified grounds and raised the contentions of territorial jurisdiction to entertain the complaint by this Forum, and they have admitted the Medi-claim policy. It is stated that the complainant submitted the claim form along with the discharge summary duly signed by the concerned doctor, and at the time of the verification of the medical records, it was found that the illness is Alcoholic Liver disease. It is further stated that such a situation, the claim of the complainant was repudiated and that matter was communicated to the complainant. It is further stated that the submission of further certificate from the doctor by the complainant, is false and frivolous one and for that the complainant is not entitled to get the amount from them. It is stated that the complainant was not entitled to get any benefit as per policy conditions.
4. Considering the disputes of the parties, the Forum has raised the following issues:-
1) Whether there is any deficiency of service on the side of the opposite parties
to release the claim amount to the complainant?
2) Whether the complainant is entitled to get the Medi-claim amount?
3) Compensation and costs.
5. Issues 1 to 3:- Complainant has filed proof affidavit in support of his claim and produced documents in evidence – Exts.A1 to A7 marked. Ext.A1 is the copy of Advocate’s Notice dt. 24.3.2011 to the 2nd opposite party by the complainant, in connection with the matter of Medi-claim amount, Ext.A2 is the Medical Certificate dt. 14.3.2011 issued by Dr.Ananthakrishnan of M/s.Travancore Medical College where the treatment was done by the complainant. The certificate shows that they have not got any proof to say that the disease was Alcoholic Liver Disease, Ext.A3 is the claim filed by the complainant, vide dt. 16.12.2010 for a sum of Rs.31,117/- after duly certified by the said doctor, Ext.A4 is the approval letter dt. 18.12.10 for a sum of Rs.15,000/- sanctioned by the first opposite party to the complainant in connection with the treatment, Ext.A5 series are the certificate and other documents of the treatment given to the complainant, Ext.A6 is the Discharge Summary issued by M/s.Amritha Institute of Medical Science and Research Centre issued to the complainant in connection with the treatment for Lower Respiratory Tract Infection and Cirrhosis liver. The certificate is silent with regard to the alcoholic liver disease and Ext.A7 is the certificate issued M/s.Upasana Hospital, Kollam in connection with the Ultrasonography of Abdomen of the complainant.
6. 2nd opposite party has filed counter affidavit with documents – Exts.B1 to B5 marked – Ext.B1 is the copy of the administrative instructions of M/s. Indian Rare Earths Limited in which the complainant was working in the firm, and the details of the scheme, Ext.B2 is the copy of the policy certificate of 2nd opposite party, and the details of insured parties, Ext.B3 is the copy of Discharge Summary of the hospital – M/s.Travancore Hospital in connection with the treatment, Ext.B4 is the copy of the repudiation letter in respect of Medi-claim and Ext.B5 is the reply notice dt. 28.4.2011 of the Advocate of the opposite parties to the complainant’s Advocate.
7. We have heard the matter in detail and perused the documents of the parties, produced in evidence and verified the entire matter involved in this case. It is alleged by that the complainant that the opposite parties are repudiated the claim furnished by him, by stating that the treatment was done due to the complaint of Alcoholic Liver Disease. Even though the complainant was an insured before the opposite parties for the medi-claim, and he has valid policy, the opposite parties are rejected the claim due to the reason of alcoholic complaint of the complainant. It is stated that the opposite parties are not liable for payment of any amount due to the said reason. On a detailed verification of the entire documents produced by both parties, we are of the view that the opposite parties jointly and severally liable to pay the claim amount to the complainant. There is no need to disbelieve the Ext.A2 certificate issued by the concerned doctor by stating that they have not got any proof to say that there is alcoholic disease of the complainant. Ext.A6 document of M/s.Amritha Institute of Medical Science is also silent with regard to the ‘alcoholic disease’. It is alleged by the complainant that earlier he had undergone treatment for the liver complaint before the Amritha Hospital and VSM Hospital and that it was not the disease of ‘alcoholic liver complaint’. Considering the detailed verification of the Ext.A2 document, it can be say that the action of the opposite parties are highly illegal and arbitrary and refusal of release of the caim of Rs.31,117/- to the complainant cannot be justified. We are of the further view that the opposite parties are acted without any bonafides and raised unnecessary contentions regarding the disease of the complainant and rejected the claim of the complainant without any sufficient and valid reason. On a detailed study of the documents produced by the parties, the contentions raised by the opposite parties have no merit and it cannot be take into account. The opposite parties are fully liable to pay the amount to the complainant. By rejection of the claim by the opposite parties they are committed deficiency in service and unfair trade practice. The contentions of the existing disease of the complainant raised by the opposite parties have no locus standi and it is ignored. So, we are of the considered view that the complainant is bound to get the Medi-claim policy amount noted above from the opposite parties. Since there is deficiency in service and negligence on the side of the opposite parties in releasing the amount in time, the opposite parties are jointly and severally liable to pay compensation and costs to the complainant. In this respect, we are of the view that the opposite parties are unnecessarily drag on the complainant before this Forum for getting proper relief from the opposite parties, and for this, the opposite parties are jointly and severally answerable to the complainant. Hence, we are of the view that the complaint is to be allowed. All the issues are found in favour of the complainant.
In the result, we hereby directing the opposite parties to sanction and release the claim amount of Rs.31,117/- (Rupees thirty one thousand one hundred and seventeen only) to the complainant in connection with the Medi-claim, and pay interest for the said amount at the rate of 9% from the date of rejection of the claim (04.01.2011) to till the date of repayment of the entire amount. Since there is deficiency in service and negligence on the side of the opposite parties, we are further directing the opposite parties to pay a compensation of Rs.10,000/- (Rupees ten thousand only) to the complainant for his mental agony, pain, harassment, purposeful refusal to release the claim amount by the opposite parties in time. We are directing the opposite parties to pay an amount of Rs.2000/- (Rupees two thousand only) as costs of this proceedings. WE further directing the opposite parties to comply with this order within 30 days from the date of receipt of this order.
Pronounced in open Forum on this the 31st day of December, 2011.
Sd/- Sri. K. Anirudhan:
Sd/- Sri. Jimmy Korah:
Sd/- Smt.N.Shajitha Beevi:
Appendix:-
Evidence of the complaiannt:-
Ext.A1 - Advocate’s Notice dt. 24.3.2011 to the 2nd opposite party by the
complainant
Ext.A2 - Medical Certificate dt. 14.3.2011 issued by Dr.Ananthakrishnan of
M/s.Travancore Medical College
Ext.A3 - Claim filed by the complainant, vide dt. 16.12.2010 for a sum of Rs.31,117/- Ext.A4 - Approval letter dt. 18.12.10 for a sum of Rs.15,000/- sanctioned by the first
opposite party to the complainant in connection with the treatment
Ext.A5 series - Certificate and other documents of the treatment given to the complainant Ext.A6 - Discharge Summary issued by M/s.Amritha Institute of Medical Science
and Research Centre issued to the complainant
Ext.A7 - Certificate issued M/s.Upasana Hospital, Kollam in connection with the
Ultrasonography of Abdomen of the complainant.
Evidence of the opposite parties:-
Ext.B1 - Copy of the administrative instructions of M/s. Indian Rare Earths Limited Ext.B2 - Copy of the policy certificate of 2nd opposite party
Ext.B3 - Copy of Discharge Summary of the hospital – M/s.Travancore Hospital Ext.B4 - Copy of the repudiation letter in respect of Medi-claim
Ext.B5 - Reply notice dt. 28.4.2011 of the Advocate of the opposite parties to the
complainant’s Advocate
// True Copy //
By Order
Senior Superintendent
To
Complainant/.Opposite parties/S.F.
Typed by:-pr/-
Compared by:-
