KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION SISUVIHARLANE VAZHUTHACADU THIRUVANANTHAPURAM
APPEAL NO. 111/2016
JUDGMENT DATED. 27-11-2018
(Appeal filed against the order in C.C.NO. 263/2014,CDRF, Wayanad)
PRESENT:
HON’BLE JUSTICE SRI.S.S.SATHEESA CHANDRAN: PRESIDENT
SRI. RANJIT. R :MEMBER
APPELLANT:
The Manager,
Star Health and allied insurance company ltd,
Branch office, Afthab building, Near Karuna hospital,
NH 212, Sulthan Bathery, Wayanad.
(By Adv. G.S. Kalkura)
V/S
RESPONDENTS:
- Mary Thomas, W/o Thomas,
Manakkal karottu house, Mylambadi post,
Sulthan bathery taluk, Wayanad.
(By Adv. V.P. Pramod )
- Eldho K.V, Kavingal house,
Mylambadi post, Krishnagiri village,
Sulthan bathery, Wayanad.
JUDGMENT
HON’BLE JUSTICE SRI.S.S.SATHEESA CHANDRAN: PRESIDENT
.
This appeal is against the order dated 15-09-2015 in CC No. 263/2014 passed by the Consumer Disputes Redressal Forum, Wayanadu, Kalpetta. The 2nd opposite party in the above complaint has filed this appeal challenging the order of the Forum directing it to pay a sum of Rs. 7,000/- with compensation of Rs. 5,000/- and costs of Rs. 3,000/- to the complainant.
(2) Short facts necessary for disposal of the appeal can be summed up thus . Complainant had taken a mediclaim insurance policy, which among others provided for cashless treatment benefit on inpatient treatment at hospital from the 2nd opposite party/appellant, hereinafter referred to as 'the insurer'. Complainant was admitted in Vinayaka Hospital, Sulthan Batheri for the period from 16-10-2014 to 23-10-2014 since she suffered from severe acute low back ache. Immediately on admission, from the hospital intimation was given to the Insurance company, to facilitate payment for her treatment expenses invoking the cashless benefit facility covered by the insurance policy . Insurance company repudiating the claim for treatment by cashless facility issued Exbt. A5 letter to the hospital stating that the ailment of the complainant did not require inpatient treatment. Complainant had to spedt an amount of Rs. 7,000/- for her treatment. After discharge from hospital alleging deficiency in service against the insurer she filed the complaint for refund of the treatment expenses with compensation of Rs. 1,00,000/- from the insurance company and also it's agent who was instrumented in collecting premium from her for the policy. The insurance company alone contested the proceedings, filing a version in which among other contentions it was contended that cashless benefit provided does not form part of the policy and it was only an additional benefit extended to the insured. Complainant did not put forward her claim for treatment expenses as provided for in the policy and without making any such claim, she approached the Forum and filed the complaint. She had pre-existing disease at the time of taking the policy and that was suppressed from the insurance company was also another contention mooted to oppose her claim contending that the policy was vitiated by fraud .
(3) Evidence in the case consists of the testimonies of the complainant and her husband as PW1 and PW2 respectively and Exbts. A1 to A18 series on her side, and that of an executive of the insurance company as DW1 and Exbts. B1 to B6 on its side .
(4) Appreciating the materials produced by counsel on both sides the forum below accepted the case of the complainant that there was deficiency in service on the part of the insurance company negating the contentions raised to resist her claim. The forum thereupon directed the insurance company to refund the treatment expenses with compensation and costs as indicated.
We heard the counsel on both sides and perused the records.
Reiterating the contentions advanced before the lower forum to oppose the claim of the complainant, learned counsel for the appellant contended that the policy, as per its terms and conditions, does not provide cashless facility but that benefit over and other benefits was extended by the insurance company as a good-will measure. Where the policy does not provide any cashless facility, any claim set forth imputing deficiency in service for non-providing of cashless facility would not enable the complainant to seek any compensation from the forum, setting forth a case that denial of that benefit amounted to consumer dispute, is the submission of the learned counsel. Complainant did not put forth a claim for treatment expenses after discharge from hospital is also highlighted by the counsel to contend that the order of the forum below awarding refund of the treatment expenses with compensation and costs to her is unsustainable.
(7) Perusing the records we find that the policy mandated intimation to the insurance company within 24 hours of hospitalization of the insured. The fact that on such hospitalization the insured is entitled to enjoy cashless facilities of the policy, whether it was given as an additional facility or not, is not disputed by the insurance company. Even assuming that the policy does provide for such a benefit in writing where the insured was informed that she is entitled to have cashless facility on hospitalization for taking the policy and thereupon premium was paid on such representation it is not open to the insurance company to deny her that benefit. We do not find any merit in that contention taken by the insurance company which, in fact, it is estopped from raising so. Exbt. A5 letter is the reply given by the insurance company denying the cashless benefit to the insured on receiving intimation from the hospital. The only reason stated for is denial as seen from Exbt. A5 is that she did not require hospitalization for the ailment suffered. When that was challenge to repudiate the claim for cashless benefit, unless that is established by the insurance company, certainly the repudiation amounted to deficiency in service when the policy enabled the insured to claim such facility. No material was placed by the insurance company in the present case in support of its contention that the disease suffered by the insured did not require inpatient hospital treatment. Though there is some force in the submission made by the counsel for the insurance company that it had been denied an opportunity to examine the claim of the complainant with reference to the treatment records since she did not submit a claim with such documents we find that has no serious consequence in the case, where the claim amount awarded towards treatment expenses is only Rs. 7,000/- . There it is established that there was deficiency in service on the part of the insurance company and claim for treatment is limited to Rs. 7,000/-, we are of the view that no further enquiry are scrutinizing of the treatment records of the complainant to substantiate her claim is called for. It is reasonable to conclude that she might have expended a sum of Rs. 7,000/- for her treatment . The direction of the forum to the insurance company to refund that sum with compensation and costs ordered is found to be just and reasonable and no interference thereof is called for .
Appeal is dismissed.
A Sum of Rs. 7,500/- deposited by appellant to entertain its appeal, shall be released to the complainant adjusting if in the sum payable, on her application before the commission. Balance amount due with interest as ordered by the lower forum shall be paid by the insurance company within a period of one month from the date of receipt of a copy of this judgment.
Both parties are directed to suffer their costs .
JUSTICE S.S.SATHEESA CHANDRAN: PRESIDENT
RANJIT. R :MEMBER
Ekm ca/ sh .
