By Sri.P.K,.Sasi, President
The case of the complainant is that he has incepted a medi claim policy of the opposite party and during the validity of the policy he has undergone treatment, for which he is entitled to get the treatment expenses reimbursed by the opposite party as per the policy. He has undergone treatment at Jubilee Mission Medical college from 12/12/17 to 21/12/17 for lower respiratory tract infection.
2. After the treatment immediately the complainant submitted a claim before the opposite party for an amount of Rs.32,715/- incurred for the complainant for the treatment. But the opposite party rejected the claim without genuine reason, which amounts to deficiency in service on their part. Hence a lawyer notice was issued on 2/4/18. Even after accepting the notice, the opposite party neither acted as per the notice nor sent any reply. Hence this complaint is filed.
3. On receiving complaint, notice was properly sent to the opposite party. Even after accepting notice, the opposite party neither appeared before the Forum nor submitted any version, despite several chances given. Hence the opposite party set exparte and posted for complainant’s evidence.
4. From the side of complainant, he has appeared before the Forum and submitted proof affidavit, in which he has affirmed and explained all the averments stated in the complaint in detail. He has also produced 7 documents, which are marked as Exts.P1 to P7. Ext.P1 is copy of discharge summary, Ext.P2 is copy of insurance certificate, Ext.P3 is copy of cash receipt, Ext.P4 is copy of letter issued by Dr.Paul T Antony, Ext.P5 is copy of rejection letter dated 22/2/18, Ext.P6 is copy of lawyer notice with postal receipt and Ext.P7 is A/D card. Since there is no contra evidence available before us, we are inclined to accept the proof affidavit filed by the complainant. We have gone through the contents of affidavit and perused the documents produced and also hard the learned counsel for the complainant in detail.
5. According to the complainant, the opposite party has rejected a genuine claim, submitted by the complainant as per the policy of opposite party incepted by him. If at all there was any contra evidence for the opposite party, they ought to have been appeared before the Forum and submitted their version. Ext.P1 discharge summary would go to show that the complainant had underwent treatment at Jubilee Mission Medical college hospital from 12/12/17 to 21/12/17. He was diagnosed with Interstitial Lung Disease Lower Respiratory Tract Infection. Ext.P2 the insurance certificate would go to show that the complainant had incepted an Easy Health Group Insurance policy with a sum insured of Rs.5,00,000/-. Ext.P4 is a copy of letter by Dr.Paul T Antony of Amala Institute of Medical Science, who treated this complainant for Rheumatoid Arthritis, which would go to show that he was under treatment for Joint pain from January 2017 onwards. Ext.P5 the rejection letter issued by the opposite party would go to show that they rejected the claim for the reason ‘the details of rheumatoid arthritis since two years is not revealed while taking the policy in the proposal form. Here the burden is upon the opposite party to prove that they have rejected the claim with genuine reason. There is no treatment records available before us to show that the complainant was having history of rheumatoid arthritis for the last two years.
6. Considering the points discussed hereinabove, we are of the opinion that the claim submitted by the complainant was rejected by the opposite party without genuine reason, which amounts to deficiency in service on their part.
7.In the result, we allow this complaint and the opposite party is directed to return Rs.32,715/- (Rupees Thirty two thousand seven hundred and fifteen only) with 9% interest from the date of complaint to the complainant within one month from receiving copy of order. There is no separate order regarding cost and compensation. Failing which, the complainant is entitled to get 9% interest for all those amount till realization.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum this the 22nd day of December 2018.
Sd/- Sd/-
M.P.Chandrakumar P.K.Sasi, Member President.
Appendix
Complainant’s Exhibits
Ext.P1 copy of discharge summary,
Ext.P2 copy of insurance certificate,
Ext.P3 copy of cash receipt,
Ext.P4 copy of letter issued by Dr.Paul T Antony,
Ext.P5 copy of rejection letter dated 22/2/18,
Ext.P6 copy of lawyer notice with postal receipt
Ext.P7 A/D card
Id/-
President
