BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

VAZHUTHACAUD : THIRUVANANTHAPURAM

PRESENT

SRI.  P.V. JAYARAJAN                              : PRESIDENT

SMT. PREETHA G. NAIR                           : MEMBER

SRI. VIJU  V.R.                                             : MEMBER

C.C.No. 233/2019  Filed on 23/07/2019

ORDER DATED: 03/01/2022

ORDER

SMT. PREETHA G. NAIR: MEMBER

                        The husband of the complaint was treated in SUT Royal Hospital Ulloor in critical stage on 23/05/2017.  Thereafter he had undergone bypass surgery on 12/06/2017 and paid Rs.5,31,433/- as per the discharge bill dated 23/06/2017.  They got Rs.3,25,000/- as Mediclaim Insurance Policy.  Balance amount of Rs.2,06,433/- was claimed from the opposite parties by the complainant.  On 13/10/2017 the complainant had given all medical bills along with the application form to the ESI dispensary Peroorkada Branch.  They had not given any information till 11/02/2019.  Then the complainant had submitted a complaint before the 1^st opposite party on the Adalath dated 12/02/2019.  But the 1^st opposite party had rejected the claim on 21/03/2019.  But the 1^st opposite party had not given the bills and other document to the complainant.  Hence this complaint.

                        After accepting the notice the opposite parties not present and opposite parties set ex parte.

                        Complainant filed chief affidavit and documents.  Ext.A1 to A7 marked.

                        Issues to be considered are:

1. Whether there is any deficiency in service on the part of opposite party?
2. If so what is the relief and cost?

            Issue Nos. (i) & (ii) : We perused relevant documents on record.  As Ext.A1 “As per Section 61 of the ESI Act, where a person is entitled to any of the benefits provided under the ESI Act, he shall not be entitled to receive any similar benefit admissible under the provisions of any other enactment.  Since the IP/Husband has already received reimbursement of Medical expenses for the same treatment through Medi Claim Policy, he shall not be entitled to again claim the same treatment expenses from ESIC.  Hence the claims is rejected”.    As per Ext.A2 the inpatient invoice summary shows the total amount of Rs.5,31,433/-.  As per Ext.A6, the complainant stated that Rs.2,00,000/- received as per Vidal health Insurance as cashless and Rs.1,25,000/- is to be paid by Vidal Health Insurance.  Thereafter the complainant claimed the balance amount of Rs.2,06,433/-to the opposite parties.  Then the opposite parties rejected the claim amount and stated that where a person in entitled to any of the benefits provided under the ESI Act, he shall not be entitled to receive any similar benefit admissible under the provisions of any other enactment.  But the opposite parties have not produced evidence to prove the terms and conditions of the Medi claim policy given to the complainant.  It is an admitted fact that the complainant’s husband incurred medical expenses of Rs.5,31,433/-.  It is also an admitted fact that the other insurance company has reimbursed only Rs.3,25,000/-.  The present claim of the complaint is only for the remaining amount of Rs.2,06,433/-.  Hence this cannot be termed as a double claim for the same treatment. Hence we find that the acts of opposite parties amounts to deficiency in service.

                        In the result complaint is allowed.  We direct the opposite parties jointly and severally to pay Rs.2,06,433/- (Rupees Two Lakhs Six Thousand Four Hundred and Thirty Three Only) as the balance amount and pay Rs.1000/- (Rupees One Thousand only) as the cost of the proceedings, within one month from the date of receipt of this order, failing which the amount except cost shall carry 9% interest from the date of order till the date of payment/realization.     

                        A copy of this order as per the statutory requirements is forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 03^rd day of January 2022.

C.C.No.233/2019

                                                                 APPENDIX

I           COMPLAINANT’S WITNESS:

               NIL

II          COMPLAINANT’S DOCUMENTS:

III         OPPOSITE PARTY’S WITNESS:

               NIL

IV        OPPOSITE PARTY’S DOCUMENTS:

              NIL

                                                                Sd/-

PRESIDENT