BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,
ERNAKULAM.
Date of filing : 25/04/2011
Date of Order : 03/11/2011
Present :-
Shri. A. Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member.
C.C. No. 210/2011
Between
James. A.V., | :: | Complainant |
Alukka (H), Anicadu, Avoly. P.O., Muvattupuzha. |
| (By Adv. Tom Joseph, Court Road, Muvattupuzha – 686 661) |
And
1. Manager, M/s. United India Insurance Co. Ltd., | :: | Opposite parties |
Branch Office, Municipal Shopping Complex, Kacherithazham, Muvattupuzha – 686 661. 2. M/s. Dedicated Health Services TPA (India) Pvt. Ltd., G-A, Saniya Apartments, Kairali Street, Asoka Road, Kaloor, Kochi – 682 017. |
| (Op.pty 1 by Adv. Jayasree. S., C.C. No. 8/516, Siva Temple Lane, Near T.D.H.S., South Cherlai, Mattancherry, Cochin – 2)
(Op.pty 2 absent) |
O R D E R
A. Rajesh, President.
1. The facts of the complainant's case are as follows :
The complainant and his family members are the beneficiaries of a Family Health Care Insurance Policy issued to the Rubber Growers and Processors Association by the 1st opposite party. The sum insured was Rs. 75,000/-. The period of insurance was from 20-12-2009 to 19-12-2010. The facts while so, the wife of the complainant underwent treatment for cervical spondylosis from 23-09-2010 to 21-10-2010. On 29-09-2010, she was subjected for anterior cervical microdiscectomy and iliac bone fusion. The complainant spent Rs. 2 lakhs towards treatment expenses. The complainant duly submitted a claim application before the 1st opposite party. The 2nd opposite party repudiated the claim by their letter dated 18-01-2010 stating untenable contentions. The complainant is entitled to get Rs. 75,000/- together with interest and compensation of Rs. 10,000/- and costs of the proceedings. Hence this complaint.
2. Version of the 1st opposite party :
The claim of the complainant was repudiated for want of necessary papers to process the claim application. The complainant did not provide the documents requested to be produced for the disposal of the claim application. In spite of three requests letters, the complainant failed to respond to the same.
3. Despite service of notice from this Forum, the 2nd opposite party remained absent during the proceedings for their own reasons. No oral evidence was adduced by the parties. Exts. A1 to A3 and B1 were marked on the side of the complainant and the 1st opposite party respectively. Ext. X1 series was marked also marked. Heard the counsel for the complainant and the 1st opposite party.
4. The points that arose for consideration are :-
Whether the complainant is entitled to get insurance claim of Rs. 75,000/- from the 1st opposite party?
Compensation and costs of the proceedings?
5. Point No. i. :- Admittedly, the complainant is a beneficiary under the Family Health Care and Personal Accident Insurance Policy issued to Rubber Growers and Processors Association for a period from 20-12-2009 to 19-12-2010 evident from Ext. B1 policy. During the currency of the policy, the complainant's wife underwent treatment at Lissie Hospital, Ernakulam. The claim of the complainant was repudiated by the opposite party vide Ext. A3 letter dated 18-01-2011 stating as follows :
“We refer to our deficiency letter dated 15/12/2010, first reminder dated 24/12/2010 and final reminder dated 03/01/2011 in which we have asked for following documents/information:
Date of joining, Indoor Case Papers, Detail Break-up of Rs. 590 Rs And 1047 Disposable Medicine Charges, First Consultation Letter Done for Spondylosis Since Its First Detection,
We regret to inform you that the above mentioned documents have not been received by us in spite of reminders send to you, till date of this letter. Due to non submission of above said documents, we are constrained to treat your claim as No Claim.”
6. At the instance of the complainant, the opposite party had produced Ext. X1 series in this Forum which go to show that the complainant has produced the necessary documents, especially the treatment records to process the claim application of the complainant's wife. However, without perusing the above documents or stating reasons thereof, the opposite party has unilaterally rejected the processing of the claim application stating 'no claim'. During evidence, the learned counsel for the 1st opposite party happened to submit that certain amounts are not payable as per the medical bills and treatment records, however not substantiated. Considering the entire circumstances in the case and the documents on record and the hearing of both the parties, we are of the opinion that the 1st opposite party is legally liable to pay the insurance claim of the complainant subject to the terms and conditions in the insurance policy together with interest at the rate of 12% p.a. from the date of this complaint till realization. Ordered accordingly.
7. Point No. ii. :- Since the primary grievance of the complainant has been met squarely order for compensation or costs are not called for which is allowed could only eventuate further unnecessary litigation which can be avoided to the betterment of both parties.
8. Resultantly, we partly allow the complaint and direct that the 1st opposite party shall pay the insurance claim of the complainant subject to the terms and conditions of the insurance policy together with interest @ 12% p.a. from the date of complaint till realisation.
The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.
Pronounced in open Forum on this the 3rd day of November 2011.
Forwarded/By order, Sd/- A. Rajesh,President.
Sd/- Paul Gomez, Member.
Sd/- C.K. Lekhamma, Member.
Senior Superintendent.
A P P E N D I X
Complainant's Exhibits :-
Exhibit A1 | :: | Copy of the Certificate of Insurance |
“ A2 | :: | Copy of discharge summary Issued from Lisie Hospital |
“ A3 | :: | Copy of the letter dt. 18-01-2011 |
Opposite party's Exhibits :-
Exhibit B1 | :: | Copy of the terms and conditions of the policy |
“ X1 series | :: | Claim form, Medical Report, discharge summary and hospital bills. |
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