BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD, THIRUVANANTHAPURAM. PRESENT SRI. G. SIVAPRASAD : PRESIDENT SMT. BEENAKUMARI. A : MEMBER SMT. S.K.SREELA : MEMBER O.P. No. 324/2003 Dated : 15.06.2009 Complainant: Manoj Radhakrishnan Nair, S/o T.R. Radhakrishnan Nair, Sree Visakh, Vivekanandapuram, Kodunganoor P.O, Vattiyoorkavu, Thiruvananthapuram-13.
(By adv. T.R. Omanakuttan)
Opposite parties:
The New India Assurance Co. Ltd., represented by its Managing Director, New India Assurance Building, 87, M.G. Road, Fort, Mumbai- 400 001. The Branch Manager, New India Assurance Co. Ltd., Branch-II, No. 26/1436, Government Press Road, Thiruvananthapuram-1.
(By adv. Sreevaraham G. Satheesh)
This complaint is disposed of after the period so specified under the Consumer Protection Act, 1986. Though the case was taken up for orders by the predecessors of this Forum on 11.02.2005, the order was not prepared accordingly. This Forum assumed office on 08.02.2008. This O.P having been taken as heard on 15.05.2009, the Forum on 15.06.2009 delivered the following: ORDER SMT. BEENAKUMARI.A: MEMBER
The case of the complainant is as follows: The complainant is holding an insurance policy under the Kudumba Arogya (KA-I) vide policy No. PSKA 1999/47/760562/80228(760502) valid from 23.06.1999 to 22.06.2004. Whileso the complainant fell ill and was under treatment at MALAR Hospital, Chennai from 02.08.2001 to 09.08.2001. He was admitted as IP on 08.08.2001 and was discharged on 09.08.2001. An arthroscopic surgery was done on 08.08.2001. He incurred a total expenditure of Rs. 25,928.20. He has submitted all his original documents in connection with the said treatment, including hospital bills, to the 2nd opposite party on 20.08.2001 claiming reimbursement of the expenditure. But the opposite parties informed the complainant that they are ready to pay the expenditure excluding the Doctor's fee paid to the hospital. The complainant not accepted the offer of the opposite party and the act of the opposite party amounts to deficiency in service, breach of contract and against the provisions of law. Hence the complainant filed this complaint before this Forum.
The opposite parties, New India Assurance Co. Ltd., filed their version contending the claim of the complainant. The opposite parties stated that the complainant is not the insured as per the alleged policy and he is not having any locus standi to file such a complaint. The alleged policy was taken by the father of the complainant Radhakrishnan Nair. He is the insured and he has submitted a claim. The complaint regarding the non-settlement of the claim can only be made by Radhakrishnan Nair who is the actual insured as per the policy. For the above reasons, the complaint is only to be dismissed. The opposite parties further submitted that the father of the complainant submitted a claim form, claiming medical expenses for the treatments undergone by his son-the complainant. Along with the claim form he has submitted 1 bill dated 03.08.2001 for Rs. 275/- along with the receipt 2 dated 03.08.2001 for Rs. 120/-, receipt 3 dated 03.08.2001 for Rs. 210/-, receipt 4 dated 06.08.2001 for Rs. 80/-, bill 5 dated 09.08.2001 for Rs. 11,213.30 and receipt 6 dated 18.08.2001 for Rs. 30/-. There was no receipt evidencing the payment of the amount of Rs. 11,213.30 as per bill dated 09.08.2001. Moreover in the claim form an amount of Rs. 14,000/- was also claimed. But there was no receipt to show that amount was paid. The 2nd opposite party made several requests to the complainant's father for producing the receipts for the amounts of Rs. 11,213.30 and Rs. 14,000/-. There was no response and hence the 2nd opposite party issued a letter dated 03.09.2002 requesting for the production of the above receipts. As there was no result, the 2nd opposite party closed the claim file and informed the matter to the insured by letter dated 26.03.2003. The insured is not entitled for the above amount of Rs. 25,213.30 as there is no documents available to show the payment of those amounts. In the absence of the necessary supporting documents, the opposite parties are legally justified in not effecting payments. The averment that the opposite parties informed that they are ready to pay the expense excluding doctor's fee is not correct. The opposite parties only insisted for the production of payment receipts which are the basic documents necessary for the settlement of a medical expense claim. The opposite parties stated that there is no deficiency in service or breach of contract on the part of the opposite parties. Hence they prayed for the dismissal of the complaint.
In this case complainant and opposite parties filed proof affidavits and documents. From the complainant's side 12 documents were marked as Exts. P1 to P12. Opposite parties produced 6 documents which were marked as Exts. D1 to D6.
Points that would arise for consideration are:- Whether the complainant is a consumer as per Consumer Protection Act? Whether there is unfair trade practice and deficiency in service from the side of opposite parties? Whether the complainant is entitled to get the reliefs and costs.
Point (i):- The father of the complainant has taken an insurance policy under the Kudumba Arogya (KA-I) vide policy No. PSKA 1999/47/760562/80228(760502) valid from 23.06.1999 to 22.06.2004. The complainant produced the policy copy before this Forum and marked as Ext. P1. As per the policy there are four persons insured and the complainant is the fourth one. In this case the opposite party argued that the complainant is not the insured as per the alleged policy and he is not having any locus standi to file the complaint and he never submitted any claim before the opposite party. But as per Ext. P1 policy copy we can see that the policy is taken for 4 persons and the complainant is the fourth one. The father of the complainant Mr. Radhakrishnan Nair has taken the policy for the complainant also. As per Consumer Protection Act, beneficiary of services is also a consumer. When a person hires services, he may hire it for himself or for any other persons. In such cases the beneficiary of these services is also a consumer. Hence the complainant is a consumer and the complaint is maintainable before this Forum.
Points (ii) & (iii):- In this case the complainant claims that as per the policy he is entitled to get the medical expenditure which he had incurred in the hospital. As per the policy conditions he submitted the medical expenditure bills and records before the opposite party for reimbursement. But the opposite informed him that they were ready to pay the expenditure excluding the doctor's fee paid to the hospital. On this point the complainant argued that every hospital bill is included with doctor's fee and no doctor will render any treatment to any patient without fees. The complainant stated that all hospital expenditure has to be reimbursed and the opposite party is liable to reimburse the doctor's fee also.
To prove his contentions the complainant has produced 12 documents before this Forum. Ext. P1 is the copy of policy Certificate No. 1999/47/760562/80228(760502). As per this policy the complainant is the 4th insured person and he is entitled to get the benefit under this policy. Ext. P2 to P4 are the copies of medical expenditure bills incurred on 03.08.2001 and 06.08.2001. Ext. P6 is the copy of details of expenditure incurred on 08.08.2001. the complainant was discharged on 09.08.2001, on that date all the dues towards the hospital were given in detail. The copy of the same was marked as Ext. P7. Ext. P8 is the copy of receipt dated 18.08.2001 for an amount of Rs. 30/-. Ext. P9 is the copy of receipt dated 08.08.2001 for the payment of advance amount of Rs. 5,000/-. Ext. P10 is the copy of discharge summary dated 09.08.2001. Ext. P11 is the copy of advocate notice issued by the complainant to the opposite parties dated 02.08.2003. Ext. P12 is the authorization certificate of the complainant authorizing his uncle A. Mohanan Nair to conduct the case for and on behalf of him.
Contending the claim of the complainant the opposite parties have produced 6 documents. The document marked as Ext. D1 is the copy of policy certificate. In the version opposite party stated that the complainant is not the insured as per the alleged policy. But Ext. P1 document produced by the opposite party itself proved that the complainant is an insured. Ext. D2 is the copy of claim form submitted by the father of the complainant on 06.09.2001. As per this document the claim amount is seen as Rs. 25,928.20 and the details of the bills and its dates are shown in this document. The opposite parties also admitted that the originals of them were submitted along with the claim form. Ext. D3 is the copy of letter issued by the opposite party to the complainant to produce original receipts issued by M/s Malar Hospital for a sum of Rs. 11,213 and 14000/- to enable them to proceed further dated 03.09.2002. Ext.D4 is the copy of letter issued by the opposite party informing the complainant that they are closing the claim file on account of the reason no response from the insured dated 26.03.2003. Ext. D5 is the copy of reply notice issued by the opposite party to the complainant dated 13.08.2003. Ext. D6 is the copy of acknowledgement card.
The opposite parties admitted that they have received the originals of Exts. P2, P3, P4, P5 and P8. The receipts for these amounts are admitted by them. This amount in total is Rs. 714.90. Hence the balance amount to be paid is of Rs. 25,213.30. In the argument note filed by the complainant it is clearly stated the details of the payment. The opposite party stated that the complainant submitted the bill for Rs. 11,213.30 and Rs. 14,000/-, he has not produced the receipt from the hospital. So they are in doubt whether these amounts are really paid to the hospital or not. To prove the payment it is to be noted that the Ext. P7 clearly shows the payment. In Ext. P7 Sl. No. 14 and 15 show the payment of Rs. 11,213.30. Rs. 5000/- was paid by cash on 08.08.2001 as per Ext. P9 document. The balance amount of Rs. 6213/- has been paid by credit card on the date of discharge from the hospital. The balance amount of Rs. 14000/- was paid by cash towards doctor's fee. The complainant's counsel had argued that the hospital was reluctant in issuing bill for doctor's fee as that was their practice. But as per the request of the complainant in Ext. P7 document they have written the receipt of Rs. 14,000/- and they have put the signature and their official seal affixed upon it. So it is also proved that the amount of Rs. 14,000/- is also paid to the hospital. Thereby the complainant has proved that the whole amount of Rs. 25,928.20 was paid to the hospital. From the above stated arguments Ext. P7 document can be treated as the receipt of the payment of Rs. 14,000/- and Rs. 11,213.30. The complainant's arguments are proved by him with sufficient pleading, documents, calculations and arguments. From the above mentioned discussions we are of the view that the complainant has succeeded to prove his case beyond doubt. Hence we find that there has been unfair trade practice and deficiency in service from the side of opposite party. The opposite parties are liable to reimburse the medical expenditure incurred by the complainant as he is an insured person. The complainant submitted all the relevant documents and receipts to the opposite parties along with claim form within time. But the opposite parties did not act promptly as per the policy conditions. They were wilfully trying to evade from their liability. It is not a fair practice. Both parties are bound to obey the terms and conditions of the insurance policy. Hence the opposite parties are liable to pay the medical expenditure incurred by the complainant.
In the result, the 1st opposite party is directed to pay Rs. 25,928.20 with 12% annual interest from 20.08.2001 to the complainant and also shall pay Rs. 2,000/- as costs to the complainant. Time for compliance one month from the date of receipt of the order. Thereafter 18% annual interest shall also carry the above said amounts till the date of realization.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 15th day of June 2009.
BEENAKUMARI. A : MEMBER
G. SIVAPRASAD : PRESIDENT S.K. SREELA : MEMBER
O.P. No. 324/2003 APPENDIX I COMPLAINANT'S WITNESS : NIL II COMPLAINANT'S DOCUMENTS : P1 - Copy of Certificate of Insurance dated 23.06.1999. P2 - Copy of outpatient bill dated 03.08.2001 issued by Malar Hospital Pharmacy P3 - Copy of receipt/invoice dated 03.08.2001 No. OPR-01- 31158 P4 - Copy of receipt/invoice dated 03.08.2001 No. OPR-01- 31130 P5 - Copy of receipt/invoice dated 06.08.2001 No. OPR-01- 31509. P6 - Copy of Drug sales bill dated 08.08.2001 P7 - Copy of Drug sales bill dated 08.08.2001 P8 - Copy of receipt dated 18.08.2001 P9 - Copy of receipt dated 08.08.2001 P10 - Copy of discharge summary. P11 - Copy of advocate notice dated 02.08.2003. P12 - Authorization certificate dated 21.12.2003. III OPPOSITE PARTY'S WITNESS : NIL IV OPPOSITE PARTY'S DOCUMENTS :
D1 - Copy of certificate of Insurance dated 22.06.2004. D2 - Copy of application form dated 06.09.2001. D3 - Copy of letter dated 03.09.2002 issued by opposite party. D4 - Copy of letter dated 26.03.2003 issued by opposite party. D5 - Copy of advocate notice dated 13.08.2003. D6 - Copy of acknowledgement card.
PRESIDENT
......................Smt. Beena Kumari. A
......................Smt. S.K.Sreela
......................Sri G. Sivaprasad | | 
