BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 18/08/2011

Date of Order : 30/10/2012

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 448/2011

Between

And

O R D E R

Paul Gomez, Member.

1. The following are the facts of the complaint :-

The wife of the complainant who was covered by insurance policy with the opposite party underwent treatment in Nangeli Hospital, Nellikkuzhi, Kothamangalam from 21-08-2010 to 28-02-2010 for cervical disc prolapse left shoulder. When a claim application was preferred before the opposite party, eventhough initially it was allowed, later they retracted and took the stance that the treatment in question was undergone in a private Ayurveda Hospital and hence not payable. But the complainant is of the view that the hospital where they took the treatment was part of Nangeli Ayurveda Medical College and hence his wife is entitled to recover the amount incurred towards medical expenses.

2. The facts of the complainant are generally accepted by the opposite party. Their only disagreement is with regard to the status of the hospital, where treatment was carried out. The opposite party contents that the said hospital is only a private hospital and hence they are not liable to reimburse the expenses of the treatment. In other words, the opposite party urges on us to dismiss the complaint with costs.

3. No oral evidence to the complainant. Exts. A1 and A2 marked on his side. No oral evidence to the opposite party also. But Ext. B1 was marked for them. The learned counsel appearing for the parties were heard.

4. The points emerging for resolution are the following :-

1. Whether the hospital where the complainant's wife had undergone treatment is an Ayurveda Medical Hospital?

2. What are the reliefs, if any?

5. Point No. i. :- There is no substantial disagreement between the parties pertaining to facts. While the opposite party contend that the hospital where treatment was carried out was a private hospital, the complainant is of the view that the said hospital is an extension of the Ayurveda Medical College. If the contention of the opposite party is upheld the complaint an be thrown out. On the contrary, if the contention of the complainant is sustained, he stands to win the case. Clause 2 1 (v) Note of Ext. B1 policy conditions states as follows :-

“In case of Ayurvedic/Homeopathic/Unani treatment, Hospitalisation expenses are admissible only when the treatment is taken as inpatient, in a Government Hospital/Medical College Hospital.”

This clause provides for two conditions for entitlement of insurance claim. First, the treatment must be as an in-patient and second, it must be either in a Government Hospital or Medical College.

6. The complainant had no quarrel with this provision. But he contends that the hospital where his wife took treatment is part of Nangelil Ayurveda Medical college, Kothamangalam. He has produced Ext. B2 certificate issued in the letter pad of Nangelil Ayurveda Medical College by Dr. Vijith Nangelil stating that Nangeli Hospital, Kothamangalam is functioning in association with Nangeli Ayurveda Medical College. It is true that the author of the document has not been examined in the Forum. But we do not find anything wrong in believing the veracity of the statement. If it is under dispute, the opposite party too could have moved the Forum to get his presence in the Forum for cross-examination. Complacency in this regard, on the side of the opposite party goes to show that they too tacitly admits the contents of the document. Hence, we hold that the hospital where the complainant's wife had treatment was part of an Ayurveda Medical College and hence the opposite party is liable to indemnify the loss of the complainant by way of expenses incurred by him towards treatment of his wife.

7. Point No. ii. :- The amount claimed in the complaint is Rs. 8,853/- along with 15% p.a. from the date of claim till realisation. It is pertinent to note that the opposite party has not raised any dispute regarding the amount of the claim. In that view, we are inclined to allow the prayer substantially.

8. Accordingly, the complaint stands allowed as follows :-

1. The opposite party shall pay Rs. 8,853/- along with interest @ 12% p.a. from the date of claim till realisation.

2. No order as to costs.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.

Pronounced in the open Forum on this the 30^th day of October 2012.

Sd/- Paul Gomez, Member. Sd/- A. Rajesh, President.

Sd/- C.K. Lekhamma, Member.

Forwarded/By Order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

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