BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD, THIRUVANANTHAPURAM.

PRESENT

SRI. G. SIVAPRASAD : PRESIDENT

SMT. BEENAKUMARI. A : MEMBER

SMT. S.K.SREELA : MEMBER

C.C. No. 18/2010 Filed on 21.11.2010

Dated : 29.09.2012

Complainants :

1. Consumer Vigilance Centre, Sreekovil, Kodunganoor P.O, Thiruvananthapuram-695 013.

    

2. Dushandan. B, Keerthi Nivas, Ayanthy, Melvettoor P.O, Varkala, Chirayinkizh, Thiruvananthapuram-695 312.

Opposite parties :

1. M/s Star Health and Allied Insurance Company Ltd., Claims Division, Vijaya Plaza, S.S. Kovil Road, Thampanoor, Thiruvananthapuram-1.

    

2. M/s Star Health and Allied Insurance Company Ltd., Branch Office, Chandra Bhaga, T.C 11/8, Plamood, Pattom Palace P.O, Thiruvananthapuram-4.

(By adv. R. Jagadish Kumar)

This O.P having been taken as heard on 20.09.2012, the Forum on 29.09.2012 delivered the following:

ORDER

SMT. BEENAKUMARI.A: MEMBER

The 2^nd complainant has taken a Medi Classic Insurance Policy Medi Family Package Plan for himself and for and on behalf of his family members on 16.11.2006. He continuously renewed the policy till 05.11.2009. The complainant states that he was undergone for a Piles Surgery in the year 2006, that is before taking the policy and thereafter another surgery was done after taking the policy for the same illness and he never claimed any amount to the opposite parties. On 23.03.2009 the 2^nd complainant was admitted in Gokulam medical College for another surgery in connection with his intestine and this matter was informed to the opposite parties. The opposite parties conducted enquiry and assured that they will reimburse the bill amount to him after discharge. Accordingly the 2^nd complainant himself paid the bill amount to the hospital and thereafter he handed over all the treatment details and bills to the opposite parties before 31.03.2009. But the opposite parties have not taken any steps to settle the claim, even after repeated requests and demands of the complainant. At last the 2^nd complainant approached the 1^st complainant and accordingly sent a notice to the opposite parties on 30.11.2009 to settle the claim. The opposite parties accepted the notice and sent a reply on 11.12.2009 with false statements that they have not received any documents to settle the claim. The complainant states that the reply of the opposite parties is against actual facts. They have already submitted all the relevant documents to the opposite parties. In that circumstance the complainant was compelled to file this complaint against the opposite parties.

Opposite parties filed version to this complaint. But thereafter they have not turned up to contest the case. In the version opposite parties stated that the claim put forward by the 2^nd complainant had no supporting documents and the allegation that the claim was supported by documents is totally false. A thorough enquiry was conducted by the opposite party and it was found that no supporting document was there to substantiate the claim. The hospital authorities had earlier communicated with the opposite party with regard to the 2^nd complainant's claim and on scrutiny of the available documents it was informed to them that cashless facility could not be considered since the hospitalization was for the management of an ailment which is related to a pre-existing condition. They also submit that if the 2^nd complainant come up with the relevant medical records, this opposite party may process his claim and if he is entitled for any claim, money as per the recitals of the policy, the same will be processed. That does not mean the liability is admitted. Regarding the letter sent by the 1^st complainant, the opposite parties have given a proper reply and hence no deficiency can be attributed. The claim put forwarded has no merits and the reliefs claimed have been evaluated in an exorbitant manner and there is no cause of action for the complainant to file this complaint. Hence they prayed for the dismissal of the claim.

The 2^nd complainant in this case filed proof affidavit and for supporting his claim he has produced 7 documents which were marked as Exts. P1 to P7.

Points to be ascertained :

1. Whether there is deficiency in service from the side of opposite parties?

2. Whether the complainant is entitled to get the reliefs sought for?

Points (i) & (ii):- Complainant in this case is a policy holder of opposite parties. He has produced the policy copies as Ext. P1 series. He had undergone a surgery for Haemorrhoids on 23.03.2009 at Sree Gokulam medical College hospital at the policy period. There is no dispute regarding this aspect. For that treatment he was hospitalized from 21.03.2009 to 27.03.2009 and for that treatment he had to pay an amount of Rs. 34,682/- as per Ext. P3 document. Ext. P5 series are the copies of discharge summary. As a policy holder the complainant has claimed the treatment expenses from the opposite parties. Ext. P2 is the copy of claim form. Complainant argued that after the treatment he has sent all the hospital records and hospital bills to the opposite parties for processing the claim. But the opposite parties never turned up to settle the claim. In that circumstance, he approached the 1^st complainant to help him. The 1^st complainant Consumer Vigilance Centre sent a notice to them on 30.11.2009 to settle the claim, that notice is marked as Ext. P6. Opposite parties sent reply to the notice stating that they have not received any documents in support of the claim as such they are not in a position to consider the claim. Ext. P7 is the reply notice. Complainant argued that the statement in the reply notice is against the facts. He had sent all the documents before 31.03.2009 to them. Opposite parties in this case have filed version, but thereafter they have not turned up to contest the case. Hence the affidavit filed by the complainant stands unchallenged. The documents filed by the complainant in support of the complaint also have not been challenged. Hence we admit the pleadings and other documents in support of the complaint and allow the complaint.

In the result, the opposite parties are directed to pay the hospital expenses, as per the policy condition, of Rs. 34,652/- along with Rs. 5,000/- as compensation and costs to the 2^nd complainant. Time for compliance one month from the date of receipt of the order, failing which 9% annual interest shall be paid for the above said amount till the date of realization.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 29^th day of September 2012.

Sd/- BEENAKUMARI. A : MEMBER

Sd/-

G. SIVAPRASAD : PRESIDENT

Sd/-

jb S.K. SREELA : MEMBER

C.C. No. 18/2010

APPENDIX

I COMPLAINANT'S WITNESS :

NIL

II COMPLAINANT'S DOCUMENTS :

P1 - Copy of policy copies

P2 - Copy of claim form

P3 - Copy of medical certificate issued by Dr. R. Sanadarsi, Sree

Gokulam Medical College, Tvpm.

P3(a) - Copy of bill issued by Dr. R. Sanadarsi, Sree Gokulam

Medical College, Tvpm for Rs. 34,682.55

P4 - Copy of advertisement issued by opposite party

P5 - Copy of discharge summary

P6 - Copy of letter dated 30.11.2009 issued by A. Ayyappan Nair

P7 - Copy of reply letter issued to Ayyappan Nair dated 11.12.09

III OPPOSITE PARTY'S WITNESS :

NIL

IV OPPOSITE PARTY'S DOCUMENTS :

NIL

Sd/-

PRESIDENT

jb