D.O.F:27/02/2020
D.O.O:02/08/2021
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.No.40/2020
Dated this, the 02nd day of August 2021
PRESENT:
SRI.KRISHNAN.K :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
Mohammed Sherief Bedira Abdulla, aged 49 years
S/o Bedria Abdulla
Baithul Mabrook, S P Nagar, Muttathody Post : Complainant
Kasaragod Taluk – 671123.
(Adv: Suresh.K.P)
And
M/s Cholamandalam M S General Insurance Co. Ltd : Opposite Party
New No. 319 (Old No. 154) Shaw Wallace Building
2nd Floor, Thambu Chetty Street
Parry’s Corner, Chennai - 600001
ORDER
SMT.BEENA.K.G : MEMBER
The brief facts in this complaint is that complainant insured with opposite party for family health care VFD plan as per policy no.2876/00000819/006/00. He availed the above policy as family floater for a total sum of Rs.2,00,000/- as per the assurance made by opposite party. During the policy period complainant’s wife was suffering from Rheumatoid arthritis and got admitted in hospital on 19/06/2019 and treated for 3 days in K M C hospital Mangalore and discharged on 21/06/2019. As per the policy Opposite Party is liable to pay the bill amount but Complainant was constrained to pay the total bill of Rs.95779/-. Even though complainant filed claim application before Opposite Party No: 2 as per the policy they failed to disburse the said amount in time. The act of Opposite party caused financial, mental and physical stress to the complainant hence the complainant prays for a compensation of Rs.1 lakh with cost of Rs.20,000/- from Opposite party.
Notice of Opposite Party deemed as served, name called absent set exparte
Complainant filed proof affidavit in lieu of chief examination and documents marked as EXt A1&A2.Heard the complainant
He questions raised for consideration are:-
- Whether there is deficiency in service on the part of Opposite party?
- If so what is the relief?
Issue no.1
The purpose of taking family health care plan is to meet unexpected treatment expenses. Complainant alleges deficiency of service on the part of Opposite party as they demanded unnecessarily documents and thus dragged processing of the claim. Ext A1 is the certificate of insurance, Ext A2 is the bill from KMC hospital Mangalore. Expecting the insurance amount complainant’s wife was admitted in the hospital. He was not prepared to pay such a huge bill at that time. Opposite party failed to release the claim in time caused heavy financial ,mental and physical strain to the complainant Ext A1 is the policy and Ext A2 is the final bill from hospital . The case of the complainant tallies with the documents produced by the complainant. In the absence of rebuttal evidence we are of the view that there is gross deficiency in service and unfair trade practice on the part of Opposite Party, complainants loss has to be compensated emergently by Opposite Party.
Issue No:2
While discussing about ‘relief ‘complainant’s claim is for Rs. 1,00,000/- which is too high and baseless. In addition to the bill amount, compensation of Rs. 25,000/-with Rs. 5000/- cost will be a reasonable relief in this case.
Therefore complaint is allowed directing Opposite Party to disburse the bill amount of Rs. 95,779/- to the complainant with a compensation of Rs. 25000/- (Rupees Twenty Five thousand only) and cost of Rs. 5000/- (Rupees Five thousand only) within 30 days from the date of receipt of copy of this order.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Health – Certificate of Insurance
A2- The final bill from KMC Hospital Mangalore.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Senior Superintendent
Ps/
