IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 26th day of November, 2013
Present : Sri. Jacob Stephen (President)
Smt. K.P. Padmasree (Member)
C.C.No.103/2013 (Filed on 23.07.2013)
Between:
Alexander Varghese,
Palliparampil House,
Thelliyoor.P.O.,
Vennikulam,
Pathanamthitta. ….. Complainant
And:
1. Life Insurance Corporation,
P.B.No.48,
Marthoma Buildings,
T.K. Road, Thiruvalla,
Pathanamthitta, rep. by its-
Manager.
(By Adv. Thomas Puthukulam)
2. Rebecca Thomas,
Malayil Chengoth,
Theliyoor.P.O.,
Vennikulam, Thiruvalla. ….. Opposite parties
O R D E R
Smt. K.P. Padmasree (Member):
Complainant filed this complaint against the opposite parties for getting a relief from the Forum.
2. Brief facts of the case is as follows: 1st opposite party is an Insurance Company and the 2nd opposite party is the agent of 1st opposite party. On 06.12.2008 complainant joined in an Insurance Plan of the opposite party in the name LIC’s Health Plus Plan for his family and paid Rs.18,000/- as instalment premium towards premium for hospitalization and domiciliary benefit for the period from 05.12.2008 to 06.12.2025. While so, on 25.09.2012 complainant’s wife was hospitalized at Kozhencherry Mar Gregorious Memorial Medical Centre for varicose treatment and surgery. She was discharged on 03.10.2012. The treatment expenses comes around Rs.44,662.77.
3. Complainant submitted the claim along with all document required before the 1st opposite party for the treatment expenses. 1st opposite party assessed the claim and send a cheque for an amount of Rs.6,900/- instead of the actual expenses of Rs.44,662.77. Complainant did not accepted the offer. The opposite party repudiated the entire claim except for Rs.6,900/- as against the assurance made by the opposite party at the time of giving the policy. Complainant requested opposite party to return all the medical bills and documents submitted by him. Opposite party released the bills and other medical documents belatedly. The above said repudiation of the claim by the opposite parties is a clear deficiency in service which caused financial loss and mental agony to the complainant. Hence this complaint for getting the treatment expenses of Rs.44,662.77 along with cost and compensation of a total amount of Rs.36,000/-.
4. Both opposite parties entered appearance and filed separate versions.
5. 1st opposite party filed version with the following contentions: 1st opposite party admitted the issuance of a policy to the complainant and his family. But the said Health Plus Policy is a unit linked policy which covers insurance plan for hospital cash benefit and major surgical benefits. As per the discharge summary the diagnosis is varicose vain and the surgery performed is ‘Endo Venous Laser Treatment’. The claim papers are received and the claim is scrutinized and processed as per IRDA regulations. It was scrutinized by the authorized doctors of medi assist India with regard to the eligibility conditions ‘policy conditions and privileges’ and after scrutiny 6 days hospital cash benefit of Rs.6,900/- was granted. Policy conditions and privileges mentions 49 number of surgeries or surgical procedures covered in the policy in issue. But the surgery performed to the complainant’s wife does not form part of the list of surgeries mentioned in the list. Hence their claim for the same is repudiated. There is no deficiency in service from the part of the 1st opposite party. Hence 1st opposite party prays for the dismissal of the suit on the basis of the above said contentions.
6. 2nd opposite party filed version with the following contentions. 2nd opposite party is the agent who had canvassed the complainant in the said policy. As an advisor he had done the after sales service of the policy correctly. 2nd opposite party submitted all the relevant documents for the claim before the 1st opposite party. After repudiation of the claim, as per the demand of the complainant 2nd opposite party contacted the 1st opposite party for getting the Xerox copy of the records. After one month 2nd opposite party informed the complainant that policy documents are returned from Bangalore and he can collect the same from the Kottayam office. There is no deficiency in service from the part of the 2nd opposite party. Hence 2nd opposite party also prays for the dismissal of the complaint against her.
7. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?
8. The evidence of this complaint consists of the oral testimony of PW1, DW1, Ext.A1 to A3 and B1 and B2. After closure of evidence, both sides were heard.
9. The Point:- Complainant’s case is that he had joined in an insurance plan of the opposite party and paid Rs.18,000/- as instalment premium towards premium for hospitalization and domiciliary benefit. On 25.09.2012 the complainant’s wife was hospitalized for varicose treatment and surgery. The treatment expenses come around Rs.44,662.77 complainant submitted the claim before the opposite party with all documents required. But the 1st opposite party assessed the claim and send a cheque for Rs.6,900/-. Opposite party repudiated the entire claim except Rs.6,900/- as against the assurance made by the opposite party at the time of issuing the policy. Moreover opposite party released the records and medical bills belatedly to the complainant. The above said repudiation of the claim by the opposite party and the delay in returning the documents is a clear deficiency in service and hence opposite parties are liable to the complainant for the same.
10. In order to prove the case of the complainant, complainant adduced oral evidence as PW1 and produced 3 documents. Documents produced were marked as Ext.A1 to A3. Ext.A1 is the policy document issued by the 1st opposite party on 06.12.2008. Ext.A2 is the photocopy of the discharge summary in the name of Rachel Alex issued from Muthoot Medical Centre. Ext.A3 is the inpatient invoice summary issued from Muthoot Medical Centre to Rachel Alex.
11. On the other hand, the contention of the opposite parties is that they have issued a health plus policy to the complainant which is a Unit Linked Health Insurance Plan which provides insurance cover for hospital cash benefit and major surgical benefit. Policy conditions and privileges, mention 49 number of surgeries or surgical procedures covered in the policy. But the surgery performed on Mrs. Rachel Varghese does not come under the list of surgeries mentioned in the policy conditions. Hence the claim is repudiated. There is no deficiency in service from their part. 2nd opposite party is only an agent of 1st opposite party and she had done the after sales service of the policy correctly. Hence there is no deficiency in service from the part of the opposite parties as alleged by the complainant.
12. In order to prove the case of the opposite party, legal manager of the 1st opposite party examined as DW1 and documents produced by him were marked as Ext.B1 and B2. Ext.B1 is the conditions and privileges referred to in the policy document. Ext.B2 is an order of the Hon’b;e National Commission in Appeal No.783/2011.
13. On the basis of the contentions and arguments of the parties, it is seen that the parties have no dispute with regard to the policy in question and the treatment of the complainant’s wife. The only dispute is that the major portion of the claim for the treatment expenses was repudiated by the opposite party. According to the complainant, the treatment under gone by his wife covered by the policy in question, whereas the contention of the opposite party is that the treatment obtained by the complainant’s wife is not covered under the policy in question. In view of the contentions of the parties, the only question to be answered is whether the surgery of the patient is covered in the health plus plan policy issued by the opposite parties. On a perusal of Ext.B1 health plus policy condition, the complainant’s wife’s surgery is not covered. At the same time, complainant has not adduced any evidence to show that the treatment in question is covered in the health plus plan policy of the opposite party. A mere claim without supporting evidence cannot be allowed. Therefore, the repudiation of the complainant’s claim for the surgery is legal as per the terms and conditions of the policy and hence there is no deficiency in service from the part of the opposite party. Therefore, this complaint is not allowable.
14. In the result, this complaint is dismissed. No cost.
Declared in the Open Forum on this the 26th day of November, 2013.
(Sd/-)
K.P. Padmasree,
(Member)
Sri. Jacob Stephen (President) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : Alexander Varghese
Exhibits marked on the side of the complainant:
A1 : Policy certificate dated 06.12.2008 issued by the 1st opposite party
in the name of the complainant.
A2 : Photocopy of discharge summary dated 03.10.2012 issued by
Muthoot Medical Centre in the name of Rachel Alex.
A3 : Inpatient invoice summary issued by Muthoot Medical Centre to
Rachel Alex.
Witness examined on the side of the opposite parties:
DW1 : Antony Alex
Exhibits marked on the side of the opposite parties:
B1 : Conditions and privileges referred to in the policy document.
B2 : Order of the Hon’ble National Commission in Appeal No.783/2011.
(By Order)
(Sd/-)
Senior Superintendent
Copy to:- (1) Alexander Varghese, Palliparampil House, Thelliyoor.P.O.,
Vennikulam, Pathanamthitta. (2) Manager, Life Insurance Corporation, P.B.No.48, Marthoma
Buildings, T.K. Road, Thiruvalla, Pathanamthitta.
(3) Rebecca Thomas, Malayil Chengoth, Theliyoor.P.O.,
Vennikulam, Thiruvalla.
(4) The Stock File.
