BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 31st day of July 2012
Filed on : 13/09/2010
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member
Smt. C.K. Lekhamma, Member
C.C. No.488/2010
Between
C.U. Philiph, : Complainant
Chennattu house, (By Adv. George Cherian
Thekkumoottil Padi, Karippaparambil, HB.48,
Piravom P.O. Panampilly Nagar, Kochi-682-036)
And
1. M/s. IFFCO Tokio General : Opposite party
Insurance, XL/1485, (1st O.P. by Adv. Saji Isaac K.J.,
First floor, Satgamaya, 311, HB Flats, Panampilly Nagar,
M.G. Road, Kochi-682 011. Kochi-682036)
2. M/s. Paramount Health (2nd OP absent)
Services Pvt. Ltd., Sreevihar,
1st Floor, O.K., Mahdavi Amma
road, Chittoor road,
Kochi-682 018.
O R D E R
A Rajesh, President.
The facts of the case leading to this complaint are as follows:
The complainant is a medishield policy holder of the first opposite party. The complainant underwent treatment at Devamatha Hospital Koothattukulam for lower respiratory track infection IHD and Hypertension from 02-02-2010 to 08-02-2010. He had to spend Rs. 12,273/- towards treatment expenses. Claim application was submitted before the 1st opposite party on15-02-2010. The 2nd opposite party requested the complainant to produce some documents to process the claim applications but the insurance claim has not been settled so far. Smt. Pennamma Philip wife of the complainant was treated at JMP Medical Centre from 29-01-2010 to 01-02-2010 for Cervical Spondilossis peri A arthritis Right shoulder. She had to spend a total sum of Rs. 2,479/- towards treatment expenses. The said claim also was repudiated by the 1st opposite party alleging that hospitalization is unwarranted for the treatment. The illegal repudiation of the claims by the opposite parties amounts to deficiency in service. The complainant is entitled to get both the claims with interest at the rate of 12% p.a. together with compensation of Rs. 5,000/- and costs of the proceedings. This complaint hence.
2. The version of the 1st opposite party is as follows:
The claim of the complainant was settled for
Rs. 3,340/- against the claim of Rs. 12,273/-. The following amounts were deducted from the claim of the complainant.
a. Admission charges of Rs. 20/-
b. Establishment charges Rs. 1020/-
c. The details regarding procedure charges were not provided by the complainant for Rs. 450/-
d. Non-medical items Rs. 14/-
e. Medicines not related to the ailment Rs. 169/-
f. Medicine prescription not available Rs. 2,450/-
g. Nature of expenses not mentioned for Rs. 4,810/-
The deduction regarding procedure charges medicines prescription not available can be proceed if the complainant submits the necessary documents which the complainant has not produced in spite of reminder. The claim for insurance of the wife of the complainant was repudiated since oral medication was given to the complainant which is not covered as per the terms and conditions of the policy. There is no deficiency in service on the part of the first opposite party.
4. Despite service of notice of this complaint the 2nd opposite party did not respond to the same for reasons of their own. Proof affidavit has been filed by the complainant. Exts. A1 to A3 were marked on his side. Neither oral nor documentary evidence was adduced by the 1st opposite party. At the instance of the complainant as per order in I.A. No. 204/2012 the opposite party produced the terms and conditions of the policy. Heard the counsel for the parties.
5. The points that came up for consideration are as follows:
i. Whether the complainant is entitled to get the insurance
claims from the first opposite party?
ii. Whether the complainant is entitled to get compensation and
costs of the proceedings from the opposite parties?
6. Point Nos. i&ii. Admittedly the complainant availed a group Medishield Insurance policy for retired employees of IFFCO. The period of insurance was from 01-08-2009 to 31-07-2010 evident from the policy documents submitted by the first opposite party. According to the complainant he is entitled to get the insurance claim for his treatment at Devamatha Hospital at Koothattukulam from 02-02-2010 to 08-02-2010 and for the treatment of his wife at JMP Medical Centre from 29-01-2010 to 01-02-2010.
7. Admittedly the complainant and his wife undergone treatement and submitted claim application before the 1st opposite party for their treatment. However the 1st opposite party allowed Rs. 3,340/- as against the claim of Rs. 12,273/-. The 1st opposite party contented that the complainant has not produced any documents to substantiate the claim for the remaining amount. Though the complainant contented that he has produced the necessary documents before the 1st opposite party to process his claim application nothing is on record to substantiate the same. Even according to the 1st opposite party, they were ready to process the claim for the rejected amount provided the complainant submitted the necessary documents even in their version. Since neither of the averments of the parties have been proved before this Forum. This Forum is of the opinion that another chance be given to both the parties to set matters right.
8. The claim for the complainant’s wife also was repudiated by the 1st opposite party stating that hospitalization is not warranted. The 1st opposite party has not produced any medical evidence to substantiate the above contention . The doctor who treated the patient alone is to decide whether a patient needs hospitalization or not. In the absence of any medical evidence we are not to accept the above contention of the opposite party as well. It is to be noted that the complainant has not produced any evidence in this Forum to prove treatment expenses incurred by the complainant’s wife. In this case also we hold that a second chance be given to both the parties to sort out the issues raised.
h. In view of the above we are partly allow the complaint and direct that the 1st opposite party shall process both the claim applications of the complainant afresh. The complainant is directed to produce the necessary documents to process the claim applications from the date of receipt of a copy of this order. The 1st opposite party shall process the claim application within a period of 45 days from the receipt of the documents. It is made clear that the above order shall not be a barrier to the first opposite party to pay the admitted amount of insurance if not yet paid.
Pronounced in the open Forum on this the 31st day of July 2012.
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainants Exhibits
Ext. A1 : Copy of letter dt. 04/03/2010
A2 : Copy of case summary and discharge record
dt. 08-02-2010
A3 series : 3 Receipts
Opposite party’s Exhibits : Nil
