IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 4th day of July, 2013.
Present : Sri. Jacob Stephen (President)
Smt. K.P. Padmasree (Member)
C.C. No. 22/2013 (Filed on 23.02.2013)
Between:
KRN Kurup,
Mavilathekkethil,
Kurampala, Pandalam P.O.,
Pin : 689 501. … Complainant.
(By Adv. R. Gopikrishnan)
And:
1. MD India Health Care Sercvice-
Private Limited, New door-
No. 260/16, 3rd Floor,
Mount Casa Blanca Building,
Anna Salai, Chennai-600 006.
2. Manager,
United India Insurance Company,
Thekedathu Building,
Pathanamthitta … Opposite parties.
(By Adv. P.D. Varghese)
ORDER
Sri. Jacob Stephen (President):
The complainant has filed this complaint against the opposite parties for getting a relief from the Forum.
2. The case of the complainant is in brief as follows: The complainant is a retired Zonal Engineer of the Steel Authority of India Limited and he is a medi-claim policy holder of the second opposite party. The said policy was introduced by SAIL through the second opposite party for the benefits of their retired employees and their spouses. As per the terms and conditions of the said policy, the policy holders are entitled to get their medical expenses within 15 days from the date of submission of the claim form. While so, the complainant’s wife had undergone a surgery on 03.07.2012 for her right eye by spending an amount of Rs. 17,626/- at a hospital approved by the opposite parties in this scheme. Thereafter, the complainant submitted a claim for the treatment expenses. But so far opposite party has not settled the complainant’s claim in spite of the complainant’s demand for the same and in spite of the clarifications given by the complainant as directed by the opposite parties. According to the complainant, he is entitled to get the treatment expenses and the non-payment of the same by the opposite parties is a clear deficiency in service which caused financial loss and mental agony to the complainant. Hence this complaint for the realization of the claim amount of Rs. 17,626/- along with 12% interest from 08.08.2012 along with compensation of Rs. 50,000/- and cost of this proceedings. He also prays for allowing Rs. 2,000/- per posting of this complaint being his daily expenses and for imposing a fine of Rs. 25,000/- against the opposite parties.
3. 1st opposite party entered appearance and counsel submitted that they have no separate version and they are adopting the version of the 2nd opposite party.
4. The second opposite party entered appearance and filed their version with the following main contentions: The first opposite party is the third party administrator to the second opposite party and the second opposite party admitted the receipt of the claim of the complainant and the said claim was forwarded to the first opposite party after scrutiny. Thereafter, the first opposite party requested the complainant twice to submit a certificate from the hospital authorities stating the eye (left or right) which was operated and to submit the empty IOL sticker bearing signature and stamp on it by the surgeon who conducted the surgery. But the complainant failed to comply the above said request. Further he had violated the terms and conditions of the policy in question by submitting a belated claim intimation. The opposite parties are waiting for the required documents. But till now the same is not received. So the claim is not so far repudiated and no repudiation letter is served on the complainant. Therefore, there is no deficiency in service from the part of the second opposite party. However, opposite parties are ready and willing to settle the claim of the complainant on receipt of the required documents. With the above contentions, second opposite party prays for the dismissal of the complaint as they have not committed any deficiency in service.
5. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?
6. The evidence of this complaint consists of the oral deposition of PW1 and Exts. A1 to A7. There is no oral or documentary evidence from the part of the opposite parties, but they have cross examined the complainant. After closure of evidence, both sides were heard.
7. The Point: The complainant’s case is that his medical reimbursement claim for Rs. 17,626/- for the treatment of his wife was not allowed by the opposite party though he had complied all the formalities required for getting his claim. So the complainant prays for allowing his complaint.
8. In order to prove the case of the complainant, he had filed a proof affidavit in lieu of his chief examination along with certain documents. On the basis of the proof affidavit, the complainant was examined as PW1 and the documents produced are marked as Exts. A1 to A6 and the document produced after the examination of the complainant is marked as Ext. A7. Ext. A1 is the photocopy of the medical bill dated 03.07.2012 for Rs. 17,000/- issued by Ahalia Foundation Eye Hospital, Pathanamthitta in respect of the treatment of his wife Omana Kurup. Ext. A2 is the copy of the discharge summary dated 03.07.2012 in connection with the treatment from the said hospital. Ext. A3 is the photocopy of the letter dated 31.12.2012 issued by the complainant in the name of the first opposite party. Ext. A4 is the postal receipt in respect of Ext. A3. Ext. A5 is the photocopy of the discharge summary dated 19.12.2011 in respect of the complainant’s wife’s previous treatments. Ext. A5(a) is the photocopy of the discharge bill dated 19.12.2011 for Rs. 16,600/- issued from Ahalia Foundation Eye Hospital, Pathanamthitta in respect of the complainant’s wife’s previous treatment. Ext. A6 is the copy of the 11th page of the terms and conditions of the policy in question issued by the second opposite party. Ext. A7 is the discharge summary dated 03.07.2012 pasted with the IOL sticker in respect of the complainant’s wife’s treatment issued from Ahalia Foundation Eye Hospital, Pathanamthitta.
9. On the other hand, the contention of the second opposite party is that though they have received the claim form of the complainant, the complainant has not submitted the relevant documents required for processing the claim. So they sent letters requesting the complainant to submit the required documents for processing the claim. But he had not produced any documents as requested by the opposite parties. In the circumstances, the complainant’s claim was not processed for the said reasons and his claim is still pending with them and they are waiting for the required documents and they are ready and willing to allow the complainant’s claim. Therefore, they argued that they have not committed any deficiency in service and hence they prays for the dismissal of the complainant.
10. But the second opposite party has not adduced any oral or documentary evidence in their favour for substantiating their contentions.
11. On the basis of the contentions and arguments of the parties, we have perused the entire materials on record and found that the parties have no dispute with regard to the treatment and the claim. The only dispute of the opposite party is that the complainant’s claim is without necessary documents required for settling the claim and the request by the opposite party for the production of the required documents is not complied by the complainant which resulted in the non-settlement of the claim. Though the opposite party contended that they have sent 2 letters on 09.09.2012 and 12.09.2012 to the complainant requesting him to submit the required documents, they have not produced any evidence for substantiating the said contention. At the same time, the contention of the complainant is that he had given necessary clarifications to the opposite parties in this regard during the telephone calls between the complainant and the opposite parties. Further, it is the case of the complainant that the doubt of the opposite parties that the claim in question is in respect of which ‘eye’ i.e. right or left is not sustainable as the first opposite party being experts can ascertain it from the details given in the discharge summary wherein the letters ‘OS’ is specifically recorded which indicates that the surgery was done in the right eye. This fact was not opposed by the second opposite party with cogent evidence. So we find no reasons to disbelieve the complainant’s allegation. In the circumstances, the non-settlement of the complainant’s claim by the opposite parties cannot be justified and the said act of the opposite parties is a clear deficiency in service. Further we observed that the non-settlement of the complainant’s claim on flimsy grounds is for protracting a genuine claim which ought not have been expected from a public undertaking company like the second opposite party. In the circumstances, this complaint can be allowed with compensation and cost against 2nd opposite party for their deficiency in service thereby this complaint is allowed as follows:
(i) The second opposite party is directed to pay Rs. 17,000/- (Rupees Seventeen thousand only) being the treatment expenses as per Ext. A1 discharge bill with 10% interest from the date of filing of this complaint till this date along with compensation of Rs. 2,000/- (Rupees Two Thousand only) and cost of Rs. 500/- (Five hundred only) to the complainant within 15 days from the date of receipt of this order, failing which the complainant is allowed to realize the whole amount with 12% interest from today till the realization of the whole amount.
(ii) The other prayers in the complaint are disallowed in the absence of supporting evidence.
Declared in the Open Forum on this the 4th day of July, 2013.
(Sd/-)
Jacob Stephen,
(President)
Smt. K.P. Padmasree (Member) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : K.R. Narayana Kurup.
Exhibits marked on the side of the complainant:
A1 : Photocopy of the medical bill dated 03.07.2012 for Rs.
17,000/- issued by Ahalia Foundation Eye Hospital,
Pathanamthitta.
A2 : Copy of the discharge summary dated 03.07.2012 issued
by Ahalia Foundation Eye Hospital, Pathanamthitta in
connection with the treatment of the complainant’s wife.
A3 : Photocopy of the letter dated 31.12.2012 issued by the
complainant in the name of the first opposite party.
A4 : Postal receipt of Ext. A3.
A5 : Photocopy of the discharge summary dated 19.12.2011
in respect of the complainant’s wife’s previous
treatment.
A5(a): photocopy of the discharge bill dated 19.12.2011 for Rs.
16,600/- issued from Ahalia Foundation Eye Hospital,
Pathanamthitta.
A6 : Copy of the 11th page of the terms and conditions of the
policy issued by the second opposite party.
A7 : Discharge summary dated 03.07.2012 pasted with the
IOL sticker in respect of the treatment of the
complainant’s wife issued from Ahalia Eye Foundation
Hospital, Pathanamthitta.
Witness examined on the side of the opposite parties : Nil.
Exhibits marked on the side of the opposite parties : Nil.
(By Order)
(Sd/-)
Senior Superintendent
Copy to:- (1) KRN Kurup, Mavilathekkethil, Kurampala,
Pandalam.P.O., Pin : 689 501. (2) MD India Health Care Sercvice Private Limited,
New door No. 260/16, 3rd Floor,
Mount Casa Blanca Building, Anna Salai,
Chennai-600 006.
(3) Manager, United India Insurance Company,
Thekedathu Building, Pathanamthitta.
(4) The Stock File.
