D.o.F:8/6/2010
D.o.O:25/7/2011
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.NO. 137/10
Dated this, the 25th day of July 2011
PRESENT:
SRI.K.T.SIDHIQ : PRESIDENT
SMT.P.RAMADEVI : MEMBER
SMT.BEENA.K.G : MEMBER
Mrs.Leena D Souza,
W/o Donald D Souza,
A/at KMC XI/666,Chakkara Bazar, : Complainant
Kasaragod Kasaba,Kasaragod.
(Adv.B.Ramakrishna Bhat,Kasaragod),
The Manager, Oriental Insurance Co.
Kasaragod Br.Kasaragod. :“ Opposite party
(Adv.S.Mahalinga Kasaragod)
ORDER
SRI.K.T.SIDHIQ : PRESIDENT
Bereft of unnecessaries
the Case of the complainant is that she along with her husband had joint in the/ Nagrik suraksha Individual policy insurance of the opposite party vide policy No.441602/48/2009/1311. As per the terms and conditions of the policy during the currency of the policy if the insured sustains any bodily injury resulting solely and directly from the accident caused by external violent and visible means, then the company shall pay the insured or his legal personal representatives as the case may be the sum assured . On 18/7/09 she received an injury due to a fall. Immediately she was taken to Uma Nursing Home Kasaragod and she was treated as inpatient from 18/7/09 to 25/7/09 and thereafter she was taken to KMC Mangalore and treated there as inpatient from 29/9/09 to 5/10/09. Even thereafter she continued treatment and incurred a sum of `35000/- towards the treatment. As per the terms and conditions of the policy the opposite party should have reimbursed the amount spent for treatment. Immediately after discharge from the hospital; complainant claimed the above amount by producing bills. Instead of paying the amount opposite party offered a meagre sum of `1000/- as the amount sanctioned and approved towards the full and final settlement of the claim stating that “company shall not be liable to make any payment under the policy for he expenses incurred in connection with any pre hospitalization and post hospitalization medical treatment’. Alleging this explanation for non payment as flimsy and unreasonable, this complaint is filed alleging deficiency in service on the part of opposite party.
2, Opposite party filed version. The complainant’s major portion of the expenses were reimbursed by the Manipal Arogya Surakha insurance and she offered an amount of ` 1000/- as the balance expenses which she entitled towards the hospitalisaion as per the conditions of the policy. As the clause under exclusion No.11 of the policy the company shall not be liable to make any payment under the policy in respect of any expenses whatsoever incurred by the insured person in respect of ‘’any pre hospitalization and post hospitalization medical treatment’ Hence there is no deficiency in service on their part and they are not liable to pay any damages. Since the complainant has insured with 2 insured companies for the very same purpose and the Manipal Arogya insurance is also a necessary party. Hence the complaint is bad for nonjoinder of necessary parties..
3. Complainant filed proof affidavit as PW1 in support of her case. Exts.A1,A2 series, A3& A4 and Ext.B1 marked through PW1. DW1 cross examined by counsel for opposite party. On the side of opposite party Sri.Viji Kumar Administrative officer of opposite party filed affidavit ,ExtsB2 to B7 marked through DW1. DW1 cross examined by the counsel for complainant. Both sides heard. Documents perused..
4. The issues to be settled in this case are whether the non-settlement of the entire claim of the complainant amounts to deficiency in service and if so what order as to relief and costs?
5. The learned counsel for opposite party relying on exclusion No.11 of Ext.B2 terms and condition of Nagrik Suraksha Policy has contended that the pre- hospitalisation and post -hospitalization medical treatment are policy and after excluding the same the complainant is entitled for ` 1000/- the balance expenses towards the hospitalization as per the conditions of policy since a major portion of the expenses were reimbursed by the Manipal Arogya Suraksha Insurance.
6. As per the complaint complainant is hospitalized on 2 occasions. One was during the days 18/7/09 to 25/7/09 and the latter was from 29/9/09 to 5/10/09. As per Ext.B2 policy the opposite party is liable to pay the expenses borne by the complainant during those periods. The complainant states that she had incurred an expense of ` 25000/- and some of the bills are produced to prove the expense incurred by the complainant, which are marked as Ext.A2 series. But on a close perusal of those bills it is seen that none of them are related to the inpatient treatment between the period 18/7/09 to 25/7/09 and 29/9/09 to 5/10/09 except one that is dtd 5/10/09 issued from KMC hospital. But Ext.A2(29) is a certificate dtd 21/10/09 issued from KMC hospital which certifies that the expenses incurred for the treatment of the complainant is about ` 10,000/-. The opposite party has no case that Ext.A2(29) is a certificate concocted for the case. Therefore we are of the opinion that the complainant is entitled for the balance expenses deducting the amount she received through Manipal Arogya Suraksha Insurance. On verifying Ext.B7 it is seen that ` 3505/-has been claimed from the company. So the balance is `10,000- `3505/-= ` 6495/-. The complainant is entitled for the said amount.
In the result complaint is partly allowed and opposite party is directed to reimburse ` 6495 /-(rounded to ` 6500/- Rupees six thousand five hundred only) to the complainant within 30 days from the date of receipt of copy of order. Failing which the opposite party is liable to pay interest for the said amount @ 9% from the date of complaint till payment. However there is no order as to costs.
Exts
A1- Nagrik Suraksha Policy schedule
A2 series medical bills
A3-Discharge summary
A4-Discharge voucher
B1- claim form
B2- Nagrik Suraksha Policy
B3-letter from PW1
B4-22/3/10-letter issued by OP
B5- AD card
B6-7/12/09- copy of letter addressed to Manipal Uma Nursing Home
B7-reply of Ext.B6
PW1-Leena D Souza-complainant
DW- Viji Kumar Administrative officer of opposite party
MEMBER MEMBER PRESIDENT
eva
