Kerala

Idukki

CC/19/2018

Yeldho Abraham - Complainant(s)

Versus

Manager Oriental Insurance Company Ltd - Opp.Party(s)

Pradeep kumar

29 Nov 2019

ORDER

DATE OF FILING : 1.2.2018

IN THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI

Dated this the 29^th day of November, 2019

Present :

SRI. S. GOPAKUMAR PRESIDENT

SMT. ASAMOL. P MEMBER

CC NO.19/2018

Between

Complainant : Padayattee Yeldo, S/o. Abraham,

Padayattil House,

Adimali P.O.,

Mannamkandom, Devikulam, Idukki.

And

Opposite Parties : 1. The Manager,

Oriental Insurance Company,

Valiyaparambil Shopping Complex,

First Floor, Pvt. Bus Stand Road,

Adimali – 685 561.

(By Adv: K. Pradeepkumar)

2. Medi Assist Insurance

TPA Pvt. Ltd. No.4/1,

IBC Knowledge Park,

Tower “D”4^th Floor,

Bannerghatta Road,

Bangalore – 560 029.

 

O R D E R

 

SRI. S. GOPAKUMAR, PRESIDENT

 

Complainant is a policy holder of 1^st opposite party under Happy policy-2015. When the complainant approached 1^st opposite party and enquired about the scheme, 1^st opposite party have explained that this policy is the best scheme in available. The peculiarity of this policy is that in the event of accident / disease, one need not take cash in their hands to meet hospital expenses. This policy covers the complainant and his wife Minimol and his children Akshai and Alton. The total coverage is floating to all policy holders and that can even be confined to any one or other members, included in the scheme and the sum assured is Rs.2 lakhs. The complainant is the policy holder of 1^st opposite party since 2007 and continuing the policy by remitting premium without break, to get benefits of treatment to certain ailments of the policy holder. The present policy having No.441792/48/2017/400 dated 28.10.2016 is valid till 29.10.2017.

(cont....2)

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The complainant further averred that on 11.10.2017, the complainant's car met with an accident near Kalady and the complainant and his wife sustained serious injuries. Immediately they were taken to Little Flower Hospital, Angamaly and underwent treatment in the emergency department.

 

After first aid, they were taken of Rajagiri Hospital, Aluva for better treatment on the same day itself.

 

Complainant's wife Minimol was admitted and treated there as Inpatient from 11.10.2017 to 25.10.2017. Total amount spent for treatment was Rs.167468/-. Opposite party admitted only Rs.1,39,648/- and illegally denied to allow the balance treatment expense of Rs.27820/-. Complainant further averred that after initial treatment from Little Flower hospital, Angamali, his condition was worsened due to high infection to the lips and in continuation of the treatment and he could not take care of himself due to the gravity of injuries sustained to his wife, the doctors advised him to admit there for recurring cleaning in hygienic atmosphere and admitted in Rajagiri hospital as IP 43162 on 20.10.2017 and discharged on 24.10.2017 and met expenses of Rs.9356/-, in addition to the expenses of Rs.14500/- incurred to the complainant for treatment in Little Flower hospital, Angamali.

 

There is a clear deficiency in service on the part of the opposite party and promised services has not been rendered and the complainant is entitled to get damages also.

 

The opposite party has refused to allow the medical expenses after accident to the sum of Rs.9356/- to the complainant and Rs.27820/- to his wife. Due to that the complainant issued legal notice to the opposite party and the opposite party refused to reply it.

 

Hence the complainant filed this petition against the opposite party seeking relief such as to direct them to allow treatment expenses to a total sum of Rs.51,676/- (9356 + 27820 + 14500). Further direct the opposite party to pay compensation and cost.

 

Upon notice, opposite parties entered appearance and 1^st opposite party filed detailed reply version by admitting the issuance of the policy and its validity. 1^st opposite party further contended that the averment in paragraph 3 of the complainant that, the complainant paid Rs.14500/- in Little Flower Hospital, Angamali is denied. Immediately upon the receipt of claim of the

(cont....3)

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complainant, 1^st opposite party entrusted 2^nd opposite party for administering the claim as per the terms and condition of the policy. After considering the claim of the complainant and after

 

verifying medical records and bills, arrived at the figure of Rs.1,18,147/- and the amount was paid to the complainant on 6.12.2017 with calculation statement. Hence the petition is defective. Petitioner has not deducted the discount shown in the medical bills, co-payment as per the terms and conditions of the policy, ailment limit and tax deducted at source.

 

Opposite party further contended that complainant is not entitled to get Rs.9356/- and Rs.27820/- as alleged because it is not payable as per the contract of insurance.

 

Evidence adduced by the complainant by way of proof affidavit and documents. Complainant was examined as PW1. Exts.P1 to P6 marked. Ext.P1 is the policy certificate. Ext.P2 is the treatment records of Little Flower hospital. Ext.P3 is the discharge summary of Rajagiri hospital. Ext.P4 is the discharge card of the complainant. Ext.P5 is the demand notice copy. Ext.P6 is the copy of postal AD card.

 

From the defence side, Jimmy Mathew, manager of opposite party was examined as DW1 and Ext.R1 policy certificate and Ext.R2 statement of calculation marked.

 

The POINT :- We have heard the counsel of both parties and had gone through the documents. It is an admitted fact that the complainant availed a family health policy from 1^st opposite party, “Happy Floater – 2015”. As per the scheme in the event of accident/disease, one need not carry cash in their hand to meet hospital expense. Total coverage is floating to all policy holder and that can even be confined to any one or other members included in the scheme and the sum assured is 2 lakhs. The policy covers the complainant, his wife and 2 children.

 

The learned counsel for the complainant vehemently argued that the opposite party wilfully neglected to honour his mediclaim fully. Instead of paying an amount of Rs.167468/-, being the medical expenses incurred to the wife of the complainant, due to the motor vehicle accident, opposite party allowed only Rs.139648/-. Like wise, opposite party purposefully denied the mediclaim of the treatment expenses which the complainant incurred in Little

(cont....4)

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Flower hospital and Rajagiri hospital, following with the accidental injuries he sustained Rs.14500/- and Rs.9356/- respectively. Evenafter the receipt of legal notice demanding the payment of that amount, opposite party failed to allow the balance treatment expenses of the wife of the complainant as well as the treatment expenses of the complainant. The act of the opposite party is clear deficiency in their service and unfair trade practice.

 

On the other hand, the learned counsel for the opposite party argued that, 1^st opposite party disbursed an amount of Rs.1,18,147/- towards treatment expenses of the wife of the complainant as calculated by the 2^nd opposite party. The complainant has not deducted the discount shown in the medical bills, co-payment as per terms and conditions of the policy, ailment limit and tax deducted at source. The counsel further stated that complainant is not entitled to get the treatment expenses, because it is not payable as per the contract of insurance policy, Ext.R1. On perusing the evidence on record, it is seen that the total treatment expenses incurred to the wife of the complainant in Rajagiri hospital was Rs.167468/-, Ext.P3. But as per Ext.R2 calculation statement of the 2^nd opposite party, it is seen that they deducted Rs.12,303/- from the actual medical expenses as non-payable reasons and also the 2^nd opposite party deducted Rs.7821/- as hospital discounts and Rs.13128/- as tax deducted at source. As per the Ext.P3 medical bills, it is specifically stated that the net amount paid by the company as medical expenses to the complainant is Rs.1,39,648/-. But by deducting the tax and non-payable reasons, the company paid only Rs.1,18,147/-. This act of the company cannot be justifiable because the Ext.P3 medical bill clearly shows that eventhough the actual remittance of the complainant towards medical expenses to his wife is Rs.1,67,468/-, the actual payment made by the insurance company is Rs.1,39,648/-. The hospital authorities arrived the calculation after made deduction as per the norms of the insurance policy. Hence 1^st opposite party is legally bound to pay Rs.21,501/-, being the difference of the net amount paid by the insurance company and the actual amount which is transferred to the account of the complainant.

 

Then regarding the insurance coverage of the complainant. Complainant claimed medical expenses in two head. He claimed Rs.14500/- for the treatment expenses, which he was incurred in Little Flower hospital, immediately after the accident. Then Rs.9356/- being the accidental expenses incurred to him for the continuous treatment for the infection of the wound he sustained in the accident, in Rajagiri hospital.

 

 

(cont....5)

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As per the conditions of the policy, the policy holder is entitled to get medical expenses for inpatient treatment alone. On perusing Ext.P2 discharge summary of the complainant from Little Flower hospital, Angamali, it is seen that complainant was not treated there as inpatient. His date of admission and date of discharge is one and same, that is, 11.10.2017. At the same time, on perusing Ext.P4, medical bills issued by the Rajagiri hospital, it is seen that complainant was treated there as inpatient from 20.10.2017 to 24.10.2017 and he has incurred Rs.9356/- as medical expenses there. Hence the complainant is entitled to get that amount alone. Moreover, no evidence is produced by the complainant to convince that whether he sustained Rs.14500/- as medical expenses in Little Flower hospital.

 

On the basis of the above discussion, the Forum is of a considered view that, the complainant is entitled to get an amount of Rs.21,501/-, being the balance treatment expenses of his wife from the 1^st opposite party company, along with Rs.9356/- being the treatment expense of the complainant. Hence in total, opposite party company is legally bound to pay Rs.30857/- in total to the complainant as per the policy discussed above.

 

Under the above circumstances, the complaint allowed in part. Opposite party company is directed to pay Rs.30,857/- being the balance medical expenses to the complainant along with 12% interest per annum from the date of complaint. No order to cost.

 

Pronounced in the Open Forum on this the 29^th day of November, 2019

 

 

 

Sd/-

SRI. S. GOPAKUMAR, PRESIDENT

Sd/-

SMT. ASAMOL. P, MEMBER

 

 

 

 

 

 

 

 

(cont....6)

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APPENDIX

 

Depositions :

On the side of the Complainant :

PW1 - Padayattee Yeldo

On the side of the Opposite Party :

DW1 -Jimmy Mathew.

Exhibits :

On the side of the Complainant :

Ext.P1 - policy certificate.

Ext.P2 - treatment records of Little Flower hospital.

Ext.P3 - discharge summary of Rajagiri hospital.

Ext.P4 - discharge card of the complainant.

Ext.P5 - demand notice copy.

Ext.P6 - copy of postal AD card.

On the side of the Opposite Party :

Ext.R1 - policy certificate.

Ext.R2 - statement of calculation

 

 

Forwarded by Order,

 

 

SENIOR SUPERINTENDENT