IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Saturday, the 30th day of April, 2015
Filed on 24..03..2015
Present
1) Smt. Elizabeth George (President)
2) Sri. Antony Xavier (Member)
3) Smt. Jasmine D (Member)
in
CC/No.93/2015
Between
Complainant:- Opposite parties:-
Sri. Vinu. M., S/o Murali 1. The Manager, HDFC SL
Sheelalayam, Avalookkunnu P.O. First Floor, Manappat Building
Alappuzha, Now residing at C/o HRH North Nada (Next to Malabar
Flight Air force Station Jewellers), Kodungalloor
Near P.M. House, Race House Pin- 680 664
New Delhi – 110 003
Represented by the father and Power 2. The Manager, HDFC Life
Of Attorney Holder Sri. Murali Second Floor JP Towers
Sheelalayam, Avalookkunnu P.O. Mullackal, Alappuzha
Alappuzha (By Adv. Saji Isaac – for opposite
(By Adv. V. Suresh Kumar) parties 1 and 2) .
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
The complaint is filed by the power of attorney holder of the complainant. The complainant had obtained a policy No.90025620 on 7.3.2014 under Health Insurance and the amount insured under the policy was to the extent of Rs.3 lakhs. On 16.5.2014 the complainant fell in the cricket ground thereby he had pain on knee of the left leg. Since the pain was continuing, he had consulted with the doctor in Lakeshore Hospital, Ernakulam on 9.7.2014. The complainant had sustained Anterior Crutiate Ligament injury due to the incident on 16.5.2014 and the complainant was advised to undergo operation. Hence the complainant was admitted in the hospital at Muttuchira, Kottayam on 21.7.2014 and surgery was done on 22.7.2014 and he was discharged on 24.7.2014. While he was in hospital he submitted claim form through the hospital to the opposite party. The complainant got a notice from the opposite party demanding document about the first doctor visit immediately after the fall. Complainant was not consulted with any doctor immediately after the fall. He produced all the documents that he had to the opposite parties. The complainant is entitled to obtain the assured benefit under the policy. The rejection of the claim of the complainant by the opposite party amounts to deficiency in service and hence the complaint is filed.
2. The version of the opposite parties is as follows:-
The claim of the complainant could not be processed as he did not submit the required documents for processing the claim. The complainant had a fall on 16.5.2014. He was hospitalized only on 22.7.2014. The complainant has not produced the document relating to his first treatment immediately after the injury. Since there has been violation of the terms and conditions of the policy opposite party is not liable to compensate the complainant.
3. The complainant was examined as PW1 and documents produced were marked as Exts.A1 to A8. From the side of the opposite parties10 documents produced and those were marked as Exts.B1 to B10.
4. The points came up for considerations are:-
- Whether there is any deficiency in service on the part of the opposite parties?
- Whether the complainant is entitled to get relief and cost?
5. According to the complainant he had a fall in the cricket ground on 16.5.2014. Since the pain was continuing he consulted the doctor at Lakeshore Hospital, Ernakulam on 9.7.2014. As per the advice of the doctor he had taken M.R.I. Scan. The MRI report is produced and marked as Ext.A4. Thereafter he had undergone surgery at Holy Ghost Mission Hospital at Muttuchira, Kottayam. The discharge summary from the Holy Ghost Mission Hospital dated 24.7.2014 is also produced and it marked as Ext.A3. It is an admitted fact that complainant had submitted the claim on 21.7.2014 for the benefits of the policy that he had taken from the opposite party. According to the opposite party the complainant was hospitalized only on 22.7.2014 ie. two months after he had sustained the injury. They also stated that complainant will not be able to sustain for two months without taking any treatment after the ACL injury that too which is completely torn. Since the complainant failed to submit the required documents they rejected the claim of the complainant. While cross examining the complainant he categorically stated that he has not gone to any hospital immediately after the fall on 16.5.2014. Ext.A3 discharge card shows that he had a history of fall while playing 2 months back. The opposite parties have no case that complainant has not taken a policy from the opposite parties. Their only contention is that the complainant has not given the initial treatment papers. But from Ext.A3 it is clear that the injury sustained due to fall while playing two months back. The complainant has no case that he has consulted with any doctors immediately after the fall. The Consumer Protection Act is a Consumer Oriental Legislation meant to protect the interest of the consumers. In the instant case it is an admitted fact that complainant had obtained policy under the Health Insurance from the opposite parties under the coverage of Rs.3 lakhs. He spent money for the treatment of his injury and it is proved on record. The opposite parties are not entitled to reject the claim of the complainant on technical matters. From the forgoing discussion, it is obvious that the opposite party committed deficiency in service by repudiating the claim of the complainant under the pretext that he has not sent the initial treatment documents immediately after the fall on the cricket ground. Ext.A2 series which are the treatment bills for Rs.78,864/- incurred by the complainant.
In the result complaint is allowed. The opposite parties are directed to pay an amount of Rs.78,864/- (Rupees seventy eight thousand eight hundred and sixty four only) with 9% interest per annum from 24.7.2014 till realization to the complainant. The opposite parties are also directed to pay Rs.2,500/- (Rupees two thousand and five hundred only) towards costs of this proceedings. Since the primary relief is granted no further amount as compensation. The order shall be complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant transcribed by her corrected by me and pronounced in open Forum on this the 30th day of April, 2016.
Sd/- Smt. Elizabeth George (President) :
Sd/- Sri. Antony Xavier (Member) :
Sd/- Smt. Jasmine D (Member) :
APPENDIX
Evidence of the Complainant:-
PW1 - Vinu. M. (Witness)
Ext. A1 - Copy of the HDFC Life insurance policy
Ext.A2series - Copy of the Medical bills
Ext.A3 - Copy of the discharge summary
Ext.A4 - Copy of the MRI request form
Ext.A5 - Copy of the letter dated 27.8.2014
Ext.A6 - Copy of the email message dated 22.9.2014
Ext.A7 - Copy of the email message dated 12.6.14
Ext.A8 - Copy of the No Claim Letter
Evidence of the opposite parties:-
Ext.B1 - Letter dated 7.9.14 sent to the complainant
Ext.B2 - Letter dated 18.9.14 sent to the complainant
Ext.B3 - Letter dated 29.9.14 sent to the complainant
Ext.B4 - Letter dated 1.11.14 sent to the complainant
Ext.B5 - Letter dated 12.11.14 sent to the complainant
Ext.B6 - Letter dated 23.11.14 sent to the complainant
Ext.B7 - Letter dated 4.12.14 sent to the complainant
Ext.B8 - Letter dated 29.12.14 sent to the complainant
Ext.B9 - Letter dated 9.1.15 sent to the complainant
Ext.B10 - Letter dated 20.1.14 sent to the complainant
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:- pr/-
Compared by:-
