DATE OF FILING :25/01/2017 

IN THE CONSUMER DISPUTES  REDRESSAL FORUM, IDUKKI

Dated this the 2nd  day of November  2018

Present :

SRI. S. GOPAKUMAR PRESIDENT

           SRI. BENNY. K. MEMBER

CC NO. 19/2017

Between

Complainant       :  Mathewkutty, S/o Thomas,

                                                                            Vadakkethakidiyel House,

                                                                            Mali P.O., Mettukuzhi Kara,

                                                                            Vandanmedu Village, 

                                                                            Udumbanchola Taluk, Idukki District.

(By Adv: Gem Korason)

And

Opposite Party                                          :  1 .  ICICI Prudential Insurance ,

                                                                              Kattappana P.O., Kattappana,

                                                                              Represented by its Manager.

                                                                        2 . ICICI Prudential Insurance, 

                                                                              Regional Office, Veeteel Estate,

                                                                              Opposite Bharat Petroleum Pump,

                                                                              Kottayam, Kumily Road, 

                                                                              Kanjikuzhi, Kottayam District,

                                                                              Represented by its Manager.

 

O R D E R

SRI. S. GOPAKUMAR (PRESIDENT)

 

The case  of the complainant is that,  

 

The Complainant had joined family health insurance scheme of the opposite parties in the year 2009 February.  The period specified was that the children will get insurance coverage till they attain 25 years and the complainant and his wife  will get insurance coverage till they attain the age of 75 years.  The insurance premium is Rs.12,500/- half yearly.  The total period of insurance prescribed was 5 years.  The complainant had properly remitted first three premiums.  After that due to some unavoidable circumstance, he failed to remit two premiums.  There was no demand or remainder from the part of the opposite parties for remitting the premium amount.  When the complainant  approached  the  opposite  parties  for  remitting  the  defaulted

                                                                                                                          (Cont.....2)

-2-

premium the opposite parties received it after conducting health check up of the complainant.

 

While so, in the year 2013 complainant sustained cyst in her uterus and intimated the matter to the opposite parties and took necessary medical assistance with their advise and instruction of the opposite parties  at Matha Hospital, Kottayam.  An amount of Rs.46,000/- was incurred to the complainant as medical expenses.  Thereafter the complainant lodged a mediclaim to the opposite parties with relevant records.  But the opposite parties informed the complainant that the claim is rejected and insisted the complainant to approach the grievance all.  As directed by the opposite parties complainant approach insurance ombudsman and his plea rejected by the ombudsman on the ground that there was a delay in remitting one premium.

 

The complainant further contented that she was regular is remitting the premium and the opposite parties failed to remained the same to the complainant, further the opposite parties accepted the defaulted premium and the policy is valid.  Hence the act of the opposite parties are denying the claim is a gross  deficiency in their service and through this complaint, complainant prayed for allowing relief such as to direct the opposite parties to pay medical expenses along with compensation and cost to the complainant.

 

Upon notices opposite parties  entered appearance.  So many chances are given to the opposite parties for filing or for contesting the matter.  But opposite parties failed to file reply version and adduces any evidence.  Hence opposite parties set exparte.

 

Evidence adduced by the complainant by way of documents.  The document filed by Ext.P1 is the ICICI Pru Health Saver Policy certificate and Ext.P2 (series) are the Medical treatment records of Mrs. Shiny Mathew, W/o the complainant.

 

Heard,

 

The point that arose for consideration is whether there is any deficiency in service from the part of opposite parties, and if so, for what relief the complainant is entitled to ?

                                                                                                                           (Cont.....3)

-3-

The Point:- It is an admitted fact that the complainant availed Family Health Insurance Scheme of opposite party company by paying an amount of Rs.12,500/- half yearly for a period of 5 years from 2009 February.  It is shown in Ext.P1 certificate.  In the meantime, while the policy was in force, the wife of the complainant was treated in Matha Hospital for the complaint of Fibroid Uterus with menorrhagia and undergone surgery there.    She was treated there as in patient from 22/10/13 to 26/10/13,  and for that purpose the complainant happened to spend an amount of Rs.43,000/- for treatment expenses.  Ext.P2 is evident for the expenses.  None of these documents and averrments in the complaint challenged by the opposite parties.

 

Under this circumstances the complaint allowed.  Opposite parties are directed to pay Rs.43,000/- towards medical expenses to the complainant as per Ext.P1 policy certificate and also direct to pay Rs.5000/- as litigation cost, failing which this amount shall carry 12% interest per annum from the date of default till the realization.

 

Pronounced in the Open Forum on this the 2nd  day of November, 2018.

                                                                                                    Sd/-

                                                                                    SRI. S. GOPAKUMAR (PRESIDENT)

                                                                                                           Sd/-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 

           SRI. BENNY. K.  (MEMBER)

 

APPENDIX

Depositions :

On the side of the Complainant :

Nil

On the side of the Opposite Party :

Nil

Exhibits :

On the side of the Complainant :

Ext.P1                     - ICICI Pru Health Saver Policy certificate

Ext.P2 (series)    - Medical treatment records of Mrs. Shiny Mathew,

                               W/o the complainant.

On the side of the Opposite Party :

Nil.

                     Forwarded by Order,

 

                                     SENIOR SUPERINTENDENT