Kerala

StateCommission

A/15/576

THE MANAGER STAR HEALTH AND ALLIED INSURANCE COMPANY - Complainant(s)

Versus

JOHNY P M - Opp.Party(s)

G S KALKURA

30 Nov 2016

ORDER

 

KERALA STATE CONSUMER DISPUTES REDRESSAL

COMMISSION  VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL NO. 576/15

JUDGMENT DATED:30.11.2016

 

 

PRESENT : 

JUSTICE SHRI. P.Q. BARKATHALI                         :  PRESIDENT

SHRI.V.V. JOSE                                                          : MEMBER

1. The Manager,

Star Health & Allied Insurance Company,                  

Ammoos Complex, Kalpetta P.O,

Vythiri Taluk, Wayanad.

: APPELLANTS

2. The Manager,

Star Health & Allied Insurance Company,      

Zonal Office, 1^st floor, Vijay Plaza,

S.S. Kovil Road, Thampanoor, TVPM.

 

(By Adv: Sri. G.S. Kalkura)

 

            Vs.

 

Johny P.M, S/o Mathai,

Plappalliyil, Smitha Nivas, Kuppadi.P.O,                      : RESPONDENT

Sulthan Bathery Taluk, Wayanad District.

 

( Amicus curiae by Adv:Sri. Narayan .R)

 

JUDGMENT

HON.JUSTICE.P.Q.BARKATHALI : PRESIDENT

This is an appeal filed by the opposite parties in CC.254/13 on the file of Consumer Disputes Redressal Forum, Wayanadu, Kalpetta challenging the order of the Forum dated, April 10, 2015 directing the opposite parties to pay to the complainant Rs.42,855/- with interest along with a compensation of Rs.5000/- and a cost of Rs.3000/-.

2.      The case of the complainant as testified by him as PW1 before the Forum and as detailed in the complaint in brief is this:-

Complainant has taken a medi classic insurance policy of the opposite parties on February 11, 2012 by remitting a premium of Rs.3858/-.  The policy was renewed till February 10, 2014.  On April 19, 2013 complainant fell down from his bike and sustained injury to his leg and hip.  He took treatment from Shrisha Hospital at Pulpally and thereafter at Ayush  Ayurveda  Hospital, Kalpetta from April 23, 2013 till May 6, 2013 spending about Rs.42,852/-.  The opposite parties rejected his claim contending that no such incident occurred.  Alleging deficiency of service complainant filed the complaint claiming the amount spent by him along with compensation and cost.

3.      Opposite parties are M/s Star Health and Allied Insurance Company Limited, Kalpetta and its head office at Thiruvananthapuram represented by the respective Managers.  They in their version contended thus before the Forum.  The validity of the policy is admitted.  In the certificate issued from the Shrisha Hospital Pulpally, Wayanadu.  It is not recorded that complainant suffered injuries due to fall from a Motor cycle.  In the certificate issued from Ayush Ayurveda Hospital, Kalpetta complainant was diagnosed to have low back pain (IVDP).  There is also some discrepancy in the date of the alleged incident.  That apart the treatment for IVDP is excluded in clause 3 of the policy.  Therefore the opposite parties have repudiated the claim of the complainant.  That being so complaint has to be dismissed.

4.      Complainant was examined as PW1 and Exts.A1 to A7 were marked on his side and on the side of the opposite parties DW1 was examined and Exts.B1 to B7 were marked before the Forum.  Exts.X1 and X2 were also marked.  On an appreciation of evidence the Forum found that complainant sustained injuries from a bike accident as alleged by him and directed the opposite parties to pay to the complainant Rs.42,855/- with interest and along with compensation of Rs.5000/- and a cost of Rs.3000/-.  The opposite parties have now come up in appeal challenging the said order of the Forum.

5.      Heard the counsel for the appellants and the amicus curiae appointed from this Commission to help the complainant.

6.      The following points arise for consideration:-

1. Whether there was any deficiency of service from the part of the opposite parties?
2. Whether the impugned order of the Forum can be sustained?

 

7.      The case of the complainant as testified by him as PW1 is that on April 19, 2013 he fall from his bike and sustained injuries and he underwent treatment spending Rs.42852/-.  The specific case of the opposite parties is that no such incident happened and that therefore they repudiated his claim.  Ext.sA1 to A7, Exts.B1 to B7 and Exts.X1 and X2 show that such an incident happened on April 19, 2013.  Ext.A1 is the insurance policy,  Ext.B3 letter issued by the opposite parties shows that opposite parties have repudiated the claim as there was misrepresentation of the facts by the complainant.  Ext.A2 is the copy of Ext.B3.  Ext.A3 is the copy of the letter given by the complainant to the opposite party stating that as there is no RTA, FIR is not registered.  Ext.B6 is the original of Ext.A3.  Ext.A4 is the certificate issued from Shrisha Hospital on April 21, 2013.  Ext.A5 is the letter issued by the opposite parties to the complainant.  Ext.A6 is the discharge summary issued from the hospital.  Ext.B4 is its original.  It is stated therein that cause of injury is fall from motor bike.  Ext.A7 is the particulars of treatment and expected amount of treatment.  Ext.X1 is the medical treatment record from Shrisha Hospital and Ext.X2 is the treatment record from the Ayush Hospital.

8.      The counsel for the appellants argued that no such incident happened on April 19, 2013 which appears to be not correct.  Ext.B2, B6 and X1 and X2 shows that such an incident happened on April 19, 2013 and that complainant underwent treatment.  Ext.A3, A6, B6 and B5 show that complainant sustained injuries due to fall from a motor bike.  Thus Forum is perfectly justified in finding that complainant sustained injuries mentioned in the discharge summary Ext.A6 and also medical records Ext.X1 and X2 due to fall from a bike on April 19, 2013.

9.      The counsel for the appellants further argued that the illness IVDP is specifically excluded in clause No.3 of the policy.  On going through clause No.3 it is seen that IVDP other than caused by an accident is only excluded.  Therefore we find no merit in the above contention of the appellants.  It follows that the appellants are not justified in repudiating the claim of the complainant and the complainant is entitled to the amount spent by him for his treatment.  The finding of the Forum on this point is confirmed.

10.    The Forum has directed the opposite parties to pay to the complainant Rs.42,855/- with interest at 12% per annum from November 8, 2013 along with a compensation of Rs.5000/- and cost of Rs.3000/-.  We find no ground to interfere with the said finding of the Forum.

In the result appeal is dismissed with cost of Rs.5000/-.

 

 

JUSTICE P.Q. BARKATHALI  :  PRESIDENT

 

 

V.V. JOSE : MEMBER

 

VL.