y Smt. Saji Mathew, Member:
The Complainant had obtained an insurance policy vide No. P/181314/01/2009/002140 from the Opposite Parties. As per the policy conditions the Opposite Parties have to reimburse all the hospital expenses of the Complainant and his family members in case of any hospitalization. On 27.10.2009, the wife of the Complainant was admitted in the MIMS hospital for treatment. She suffered from pain and swelling at the wrist. The hospital expense was Rs.8,100/- and the Complainant filed claim for the same with Opposite Party. The claim was repudiated by the Opposite Party without any reason. This is deficiency in service on the part of the Opposite Parties. Therefore the Complainant prays for an order directing the Opposite Parties to give the Complainant the hospital expense of Rs.8,100/- with 18% interest and Rs.10,000/- as compensation and 2,000/- as cost of the case.
2. The Opposite Parties filed version and admitted the policy. They state that the reimbursement of the hospital expense of the Complainant and his family is subject to the terms and condition of the policy. As per the condition No.3 of the policy, hospitalization should be informed to the Opposite Parties within 24 hours. As per condition 4, the claim should be filed within 15 days from the date of discharge from the hospital. In this case the claim form and treatment records were received by the Opposite Parties only on 11.12.2009 ie after 43 days. Hence the claim was repudiated by the Opposite Parties. Later, the Complainant requested the Opposite Party to reconsider the claim explaining the circumstances of delay in filing the claim. Then the Opposite Parties took a sympathetic view and reopened the claim for processing. On perusal of the documents it is found that the patient has undergone an MRI Scan and submitted the bill for the same. But the Complainant has not submitted the MRI scan film and report. As the MRI report and film are essential for the medical scrutiny regarding the nature, duration and gravity of the illness, the Opposite Parties requested the Complainant to submit these documents by registered A.D Letter dated 24.07.2010. The Complainant had not submitted these necessary documents inspite of the reminder notice of the Opposite Party. The non submission of requisite treatment document relating to a claim under processing is a violation of condition NO.5 of the policy. Hence the claim was repudiated and there is no deficiency in service on the side of the Opposite Parties. Hence they pray for an order dismissing the complaint.
3. The Complainant was examined as PW1. Document was marked as Ext.A1. The MRI Scan Films were marked as MO1 series 4 in number. The 1st Opposite Party was examined as OPW1. Documents were marked as Ext.B1 to B12 on the side of the Opposite Parties.
4. The matters to be decided are:-
Whether there is any deficiency in service on the part of the Opposite Parties?
Whether the Complainant is entitled for any relief.
5. Point No.1:- The Opposite Parties themselves admit the policy and the expense incurred upon hospitalization of the Complainant's wife. The only objection for allowing the claim is non production of the MRI scan report and films. That report and films were produced in the Forum and marked as Ext.A1 and MO1 series. The repudiation of a genuine claim sticking on strict formalities is deficiency in service on the side of the Opposite Parties. Hence point NO.1 is found against the Opposite Parties.
6. Point No.2:- The Opposite Parties admit that medical bills for Rs.6,095/- were produced by the Complainant. Exts.B6 and B8 to B12 amount to Rs.6,095/-. The Complainant is entitled to get this amount from the Opposite Parties with reasonable costs and compensation.
Hence the complaint is partly allowed and the Opposite Parties are directed to pay Rs.6,095/- (Rupees Six thousand and Ninety Five only) on the insurance claim and Rs.1,000/- (Rupees One thousand only) as compensation and Rs.500/- (Rupees Five hundred only). The Opposite Parties are also directed to pay an interest on the ordered amount of Rs.7,595/- (Rupees Seven thousand Five hundred and Ninety Five only) at the rate of 10% per annum from the date of complaint till payment.
Pronounced in open Forum on this the day of 30th April 2011.
Date of filing:05.10.2010.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
/True Copy/ Sd/-
PRESIDENT, CDRF, WAYANAD.
A P P E N D I X
Witness for the Complainant:
PW1. Sunil George Complainant.
Witness for the Opposite Party:
OPW1. Ratnakumar Branch Manager, Star Health & Allied Insurance Company Ltd.,
Exhibit for the Complainant:
A1. MRI of Right Wrist.
MO1 series (4 in number) MRI Scan Films.
Exhibit for the Opposite Party:
B1. Copy of Claim Rejection Letter. dt:06.03.2010.
B2. Copy of Letter. dt:24.04.2010.
B3. Copy of Letter. dt:24.07.2010.
B4. Copy of Reminder Letter. dt:28.08.2010.
B5. Family Health Optima Insurance Plan.
B6. Copy of Receipt. dt:27.10.2009.
B7. Copy of Status of Intimation No:CLI/MIG/2010/181314/0053803.
B8. Copy of Discharge Bill. dt:28.10.2009.
B9. Copy of Bill. dt:25.07.2009.
B10. Copy of Outpatient Bill. dt:25.07.2009.
B11. Copy of Bill. dt:27.10.2009.
B12. Copy of Bill. dt:27.10.2009.
