By Smt. Padmini Sudheesh, President:
The case is that the complainants were policyholders of respondent for the period from 12.12.06 to 11.12.07. The second complainant has undergone treatment entitling her to get insurance amount. She applied to get the claim amount. But it was not given. The admission at the hospital was on 23.3.07 and the discharge was on 10.4.07. The treatment was at Vaidyaratnam Ayurveda College Hospital and incurred expenses of Rs.5954.64. The rejection of claim is a deficiency in service of respondent. So a lawyer notice was sent but no remedy. Hence the complaint.
2. The counter averments of respondent are that the respondent admits that this respondent has issued an individual mediclaim policy in the name of first complainant for a period from 12.12.06 to 11.12.07. As per the policy in case of Ayurvedic/Homeopathic/Unani treatment hospitalization expenses are admissible only when the treatment is taken as inpatient in a government hospital/medical college hospital. The terms and conditions are issued to the complainant along with the policy schedule. As per the letter of TTK the claim is rejected on the above ground. As per the averments in the complaint the mother of first complainant was admitted at Vaidyaratnam Ayurveda College Hospital on 23.3.07 and discharged on 10.4.07 for “Sandhigatha vatham”. The claim is submitted for ayurvedic treatment in the ayurvedic hospital. The claim is not maintainable as per the terms and conditions of the policy. Hence TTK rejected the claim on 7.9.07. No deficiency in service committed by this respondent. TTK is a necessary party to be impleaded in this case. So the complaint is bad for non-joinder of necessary parties. Hence dismiss.
3. The points for consideration are that:
(1) Whether there was any deficiency in service from respondent?
(2) Other reliefs and costs.
4. The evidence consists of oral testimony of PW1 and PW2, Exts. P1 to P3 and Exts. R1 to R6.
5. Points: The complaint is filed to get treatment expenses from the respondent Insurance Company. But the claim is rejected by stating that the patient was taken treatment at Vaidyaratnam Ayurveda Hospital and which is not a government hospital. According to the company in order to get reimbursement of medical expenses the treatment should be taken from the government hospital.
6. The second complainant is examined as PW1 and Exts. P1 and P2 are marked through her. It is her version that the exclusion of private hospitals is not intimated to her at the time of policy. At the same time she admitted that no treatment was taken from government hospital. It is the contention of company that the treatments at private hospital are excluded from the purview of the policy. The company produced copy of the policy terms and conditions and clause-2 would show that in case of Ayurvedic treatment hospitalization expenses are admissible only when the treatment is taken as inpatient in a government hospital/medical college hospital. While examining as PW1 the second complainant stated that the policy is with her. But no policy is produced to show her claim.
7. It is the reason for rejection of claim of PW1 that the treatment was taken from private hospital. Ext. P3 is a certificate issued from Vaidyaratnam Ayurveda College by which it can be seen that the said hospital is a government aided institution affiliated to University of Calicut. The principal of the college is examined as PW2 and Ext. P3 is marked through him. It is also his version that the said institution is a government aided institution. The salary to the employees are made by the Government of Kerala. But it is not a Government College and it is managed by private persons. The government is giving aid only and it is only a government aided institution. It is not in strict sense a government hospital or medical college hospital. Ext. R1 would clearly define the nature of hospital. PW1 deposed that the policy is with her but not produced. If this condition is not stated in the policy issued to PW1 definitely she will be entitled for the claim amount. But it is not done. So as per the policy she is not entitled to get any amount.
8. In the result the complaint stands dismissed.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum this the 28th day of September 2012.
