By.Smt. Bindu. R, President:
The case of the Complainant is that the Complainant is a member of Mullankolly Milk society and a diary farmer and had joined the mediclaim insurance scheme setup by Milma as Sl No.77. Complainant states that as per the scheme, if the diary farmer or his family members are treated as inpatient in a hospital, the 2nd Opposite Party will bear the entire expenses. The premium is also paid by the Complainant to enroll in the scheme through the society and the 2nd Opposite Party had issued the policy bearing No.441101/48/18/469 to the members of the scheme. The Complainant states that the mother of the Complainant named Rosamma was admitted in the hospital on 04.04.2018 and she was in the hospital till 06.04.2018 and the Complainant had to spent Rs.17,376/- towards the hospital expenses. After the treatment the Complainant had submitted, the records and bills for the treatment to the 2nd Opposite Party along with the claim petition through the society which is numbered as Claim No.117041800519 MRCMPU, Calicut 69-2017 and the same was forwarded to the 1st Opposite Party for processing the claim. But till date the claim amount is not given to the Complainant, which is deficiency of service from the side of the Opposite Party. Hence the complaint for a direction to the Opposite Party to release Rs.17,376/- with 12% interest and also for compensation of Rs.25,000/- towards the mental agony and the loss sustained to the Complainant.
2. When notice was issued from the Commission, 1st Opposite Party did not turned up even though notice was served to the 1st Opposite Party and set ex-parte on 31.01.2020.
3. The 2nd Opposite Party filed version contenting that the complaint is not maintainable either in law or on facts and the complaint has no locus standi to file the complaint. The complaint is bad for non-joinder of parties since the Malabar Regional Co-operative Milk Producers Union Limited, Kunnamangalam, Kozhikode and the Mullankolly Milk Society are necessary Parties to the above proceedings for proper adjudication. It is contented by the 2nd Opposite Party that the membership of the Complainant in the society and the averment that the Complainant and his family members are covered by the mediclaim policy of Opposite Parties and the payment of insurance premium etc are to be proved by the Complainant. The 2nd Opposite Party contented that the patient named Lisamma is not covered by the mediclaim policy with the 2nd Opposite Party and hence the Complainant is not at all entitled to get any relief as prayed for in the Complainant. The 2nd Opposite Party submitted that in all the medical records and the documents, shows the name of the patient, as “Rosa Abraham”. In the claim form submitted by the Complainant also the name of the person hospitalized is shown as Rosamma, which is not “Lisamma” as stated in the complaint and the name of the hospital is also not mentioned by the Complainant. It is also submitted by the 2nd Opposite Party that the 2ndOpposite Party is ready to admit and satisfy the mediclaim of the insured up to the eligibility quantum as and when the Complainant produce a Certificate from the proper authority stating that Lissamma and Rosa Abraham and Rosamma are one and the same person. Moreover it is admitted by the 2nd Opposite Party that the processing of the claim for disbursing the same has been completed and it is stated by the 2nd Opposite Party that without contacting the 2nd Opposite Party and without getting the proper instructions, the Complainant approached the Commission by filing the complaint. The 2nd Opposite Party was always ready to direct or help the Complainant in proper way to proceed with his mediclaim application. The 2nd Opposite Party contented that the Complainant is not entitled to the mediclaim as prayed in the complaint and the 2nd Opposite Party submitted that there is no deficiency of service from the side of the Opposite Party and hence prayed for dismissal of the complaint with cost.
4. After starting of the evidence, the Complainant filed I.A.455/2022 to correct the name of the mother of the Complainant as Rosamma which is wrongly stated as Lissamma and the I.A was allowed on costs as per the Order dated 22.10.2022. The 2nd Opposite Party filed additional version stating that the name of beneficiary in the mediclaim/insurance policy is very material as far as the insurance claim is concerned and the 2nd Opposite Party contented that neither one and the same certificate nor any other documents is produced by the Complainant to prove the name of the beneficiary. The documents produced by the Complainant is seen against the amendment and prayed for dismissal of the complaint with compensatory costs.
5. The evidence in this case consists of the oral evidence of PW1 and PW2 and Exts.A1 to A4 from the side of the Complainant and Exts.B1 to B7 (marked as subject to proof) from the side of the 2nd Opposite Party.
6. The following questions are coming up for consideration:-
- Whether the Complainant had proved the case on merits?
- If so, the compensation and costs to be awarded to the Complainant?
7. Heard both sides and perused the records, in detail.
8. During cross examination, the Complainant deposed that he took the policy through the Mullankolly Milk Society and a portion of the premium was paid by the Complainant and the balance amount is collected from the Society. At the time of taking the policy a proposal form was given in which the mother Rosamma, Complainant’s wife Bindu, son Alwin and daughter Sneha are included in the policy. The claim was for the hospitalization of Complainant’s mother Rosamma and Complainant also deposed that the mother has another name Rose Abraham. It is also deposed that “Lisamma”is not related to the Complainant. It is also deposed by the Complainant that “claim form sâIqsS bills, discharge summary bnepw tdmk A{_lmw F¶mWv. A{_lmw Fsâ AÑsâ t]cmWv”. It is also deposed by the Complainant that now the mother is no more and hence there may be difficulty in producing the one and same Certificate. The Secretary of Mullankolly Milk Society was examined as PW2, who deposed that mediclaim insurance scheme was there for the members of the society and it is deposed that the Complainant is a member of the society and as per the scheme the insured and the family members of the insured are entitled to the insurance in case hospitalisation. It is also deposed that the claim applications are send through the society, as in the case of the Complainant. It is deposed by PW2 that the documents mentioned in Ext.A1 will be given to the company along with the claim form. It is also deposed by PW2 that “]cm-Xn-¡m-csâ A½ tdmk-½, tdmkv, tdmkv A{_lmw F¶o t]cp-I-fn BWv hnfn-¡p-¶-Xv. `À¯m-hnsâ t]cv A{_lmw F¶m-Wv”. It is also deposed by PW2 that “proposal form verify sNbvX-Xn-\p-ti-j-amWv insurance company bv¡v Ab-¡p-¶-Xv”. “In para 6 of the version, the 2nd Opposite Party admits that they are ready to admit and satisfy the mediclaim of the insured Complainant, up to its eligibility quantum, immediately as and when the Complainant produces a certificate from the proper authority stating that Lisamma, Rosa Abraham and Rosamma are one and the same person”. Considering the entire pleadings and evidence in toto, it reveals that the name was wrongly and by mistakenly mentioned as “Lisamma” in the complaint which is an in advertant mistake and the evidence shows the name of the mother of the complaint is Rosamma who is also known a Rose Abraham. In Exts.B1 to B7, the documents produced by the 2nd Opposite Party, the name shown as Rosamma/Rose Abraham. Since there is no contra evidence from the side of the Opposite Party, it is to be presumed from the available evidence that Rosamma and Rosa Abraham are one and the same person who is the beneficiary under the policy and the Commission is of the opinion that the Complainant had proved his case on merits and accordingly point No.1 is found in favour of the Complainant.
9. Since point No.1 is found in favour of the Complainant the following orders are issued.
- The 2nd Opposite Party being the insurance company is directed to pay an amount of Rs.17,376/- (Rupees Seventeen thousand Three hundred and Seventy Six only) towards the expenses incurred for the hospitalisation expenses of Rosamma to the Complainant.
- The 2nd Opposite Party is also directed to pay Rs.10,000/- (Rupees Ten thousand only) towards compensation.
- The 2nd Opposite Party is liable to pay Rs.5,000/- (Rupees Five thousand only) towards the costs of the proceedings.
10. The above order is to be complied with by the 2nd Opposite Party within
one month of receipt of the copy of this order, other wise the 2nd Opposite Party will be liable to pay 8% interest from the date of order till realisation except for the amount awarded as costs.
Hence CC is partly allowed.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 13th day of September 2023.
Date of filing:29.11.2019.
PRESIDENT : Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:
PW1. A.A. James. Complainant.
PW2. Vinod Kumar P.R. Secretary, Mullankolly K.S.S.Ltd.,
Witness for the Opposite Parties:
Nil.
Exhibits for the Complainant:
A1. Copy of Letter. dt:11.04.2018.
A2. Copy of IP Final Bill Invoice. dt:06.04.2018.
Exhibits for the Opposite Parties:
B1. Copy of Color Doppler Echocardiography Report.
B2. Copy of Claim Form- Part B.
B3. Copy of Discharge Summary.
B4. Copy of Claim form- Part A.
B5. Copy of Letter. dt:11.04.2018.
B6. Copy of Letter. dt:18.05.2018.
B7. Coy of Report of Assessment.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
