By. Sri. Ananthakrishnan. P. S, President:
This is a complaint filed under section 12 of the Consumer Protection Act 1986.
2. The complainant’s case in brief is as follows: - The complainant had availed Family Health Optima insurance policy for the period from 21.03.2016 to 20.03.2017 from the second opposite party. Thereafter, on 14.02.2017, the complainant met with an accident at Kappumchal near Panamaram at about 8 pm when he was riding on his bike. After the accident, he was admitted in Leo Hospital, Kalpetta on the same day itself and discharged at request on 16.02.2017 to treat in KIMS, Al-shifa Health Care, Perinthalmanna. He was admitted in KIMS Hospital on 17.02.2017 and got discharged on 20.02.2017. The Complainant informed
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the opposite parties about the accident and treatment in both hospitals. Even though, said two hospitals are cashless hospital as per the policy, he has paid the hospital expenses on undertaking by the opposite parties that the amount paid by the complainant to the hospitals and other expenses will be refunded. After the payment of the bills and other expenses, the complainant furnished documents to the opposite parties within the time stipulated to get the insurance policy amount. But the opposite parties repudiated the claims on 14.03.2017 and 29.04.2017 on a false ground that the accident was occurred under the influence of intoxication and so, it is not covered under the policy. The complainant was neither under intoxication nor under the influence of it at the time of accident. The accident was occurred while the complainant was about to save a pedestrian who suddenly crossed the road. Even though, the complainant contacted the doctor who allegedly gave the opinion that the complainant was intoxicated, the doctor was not aware of any such allegation of intoxication. Therefore the complainant issued a lawyer notice to the Opposite parties demanding to furnish the copy of treatment records. Even though, the opposite parties have received the notice, there was no response from them. The complainant never believed that the doctor who treated him issued such a certificate. If the doctor who treated has issued such a certificate, it may be for the reason that the complainant was discharged from Leo hospital at his request or the alleged doctor might have been influenced by the opposite parties. The repudiation of the claims by the opposite parties is nothing but their deficiency of service and unfair trade practice. The complainant has incurred an amount of Rs.74,355/- for the treatment and opposite parties are liable to pay it. The intention of opposite parties is to pressurise the complainant to agree for a nominal amount under the pretext of settlement. The opposite parties have not obtained any
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explanation from the complainant before repudiating the claims. Hence this complaint to get the treatment expenses of Rs.74,355/- and compensation of Rs.25,000/- for physical and mental agony with cost.
3. Both the opposite parties filed separate versions by taking similar contentions. So, for the sake of convenience, I have to narrate their contentions together in brief as follows: - They admitted the accident occurred to the complainant. They have no dispute that the complainant admitted in Leo Hospital and KIMS Al-shifa Perinthalmanna for treatment. They also admitted that the complainant presented two claims and those were repudiated by them. There was no deficiency or unfair trade practice from their side in repudiating those claims. The doctor who has seen the complainant first has reported that the complainant was intoxicated at the time of accident. As per the terms and conditions of the policy, the company is not liable to pay any expenses incurred at hospital if the complainant was intoxicated. After presenting the claim, the opposite parties verified the documents produced from the hospitals and found that the accident was occurred to the complainant due to the use of alcohol while driving. They denied that they concocted documents to repudiate the claims of the complainant as alleged. They repudiated the claims of the complainant on a valid ground. Hence the complainant is not entitled to get the treatment expenses, compensation and cost.
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4. On the above contentions, the points for consideration are:-
1. Whether there is any deficiency of service and unfair trade practice from
the opposite parties, if so, whether the complainant is entitled to get
anything as requested?
2. Relief and Cost.
5. The evidence in this case consists of oral testimony of PW1, OPW1, Ext.A1 to A7, Ext.B1 to B11 and Ext.X1 series. Heard both sides.
6. Point No.1:- This is a complaint filed by the complainant to get insurance claim from the opposite parties. The complainant took an insurance policy from the second opposite party for cashless treatment. Ext.A1 is the policy schedule. Opposite parties admitted Ext.A1. It is an admitted fact that on 14.02.2017, the complainant met with an accident at Kappumchal near panamaram at about 8 pm and he was treated in Leo hospital Kalpetta and KIMS Al-shifa, Perinthalmanna. He was admitted there on 14.02.2017 and 17.02.2017 respectively. It is an admitted fact that the complainant presented two claims for the treatment expenses incurred by him at Leo hospital Kalpetta and KIMS Al-shifa Perinthalmanna. It is also an admitted fact that the opposite parties repudiated those two claims by accepting the opinion of the doctor that the complainant was intoxicated.
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7. The specific case of the complainant is that he was not intoxicated at the time of accident and the doctor who treated him in Leo hospital has created a false document in order to help the opposite parties to repudiate the claim of the complainant. On the other hand, the opposite parties specifically alleged that the Doctor who treated the complainant at first has opined that the accident was occurred due to the intoxication of the complainant. According to them, as per exclusion clause of terms and conditions of the policy, the company is not liable to make any payment if the accident was occurred due to intoxication. The complainant produced Ext.A1 to A7 to substantiate his claims. The opposite parties produced Ext.B1 to B11 to substantiate the repudiation of claims. Ext.B1 contains medical certificate of the complainant issued from the Leo Hospital which shows that the complainant was intoxicated at the time of medical examination. Ext.X1 series are the documents pertaining to the insurance of the complainant. Ext.B3 is the terms and conditions of the policy. Clause 3(6) of Ext.B3 provides that the company shall not be liable to make any payments under the policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of use of intoxicating drugs, alcohol, smoking and tobacco chewing. The opposite parties contented that they repudiated the claims of the complainant as per this exclusion clause. We do admit that as per Ext.B1, the doctor who treated the complainant opined that the complainant was intoxicated at the time of accident. But, the doctor has not recorded how he reached in to such a conclusion. Moreover, doctor has not opined that the complainant was intoxicated to such an extent which led to the accident. The opposite parties specifically contented in their version that the accident to the complainant was occurred under the intoxication which is not covered under the policy. Ext.A5 and A6 are the repudiation letters issued by the opposite parties to the
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complainant. It is seen in Ext.A5 and A6 that opposite parties dealt the accident of the complainant under the head of accidents which is occurred under the influence of alcohol. But the doctor has not opined that the complainant was under the influence of alcohol at the time of accident. The opposite parties have not examined the doctor who issued Ext.B1 Medical Certificate to prove that the complainant was under the influence of alcohol or accident to the complainant was occurred due to use of alcohol. Ext.B1 certificate does not indicate the mode of examination adopted by the doctor to come in to such a conclusion. As I already stated, the exclusion clause contains that the company is not liable to make any payment, if the accident was occurred due to intoxication. In this circumstance, the competent person is the doctor in Leo hospital who treated the complainant or issued Ext.B1 certificate to affirm that the complainant was under the influence of alcohol which led to the accident. But, as I already stated, the opposite parties have not examined the doctor for the reason known to them alone. Moreover, we have marked Ext.B1 subject to proof. So, the opposite parties are bound to adduce further evidence to prove Ext.B1 by examining the same doctor or any one of the doctors who is familiar to the handwriting or signature of the doctor who issued Ext.B1. Since, opposite parties have not done so, they have not proved Ext.B1 properly. So, Ext.B1 cannot be looked into to find out whether the complainant is disentitled to get the claim amount or not. Therefore, here there is no sufficient materials to conclude that opposite parties had repudiated the claim of the complainant for a valid reason. So we can hold that here there is deficiency of service and unfair trade practice from the side of the opposite parties. Thus, the Point No.1 is answered in favour of complainant.
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8.Point No.2:- The claim of complainant is for Rs.74,355/- towards treatment expenses. He has produced Ext.A3 and A4 bills. Ext.A3 and A4 bills show that the complainant is only entitled to get treatment expenses of Rs.67,774/-. Since the opposite parties have repudiated the claim of the complainant without a valid reason, according to us, he is entitle to get compensation of Rs.5,000/- for physical and mental agony and Rs.1,000/- towards cost of the proceedings.
In the result, the complaint is allowed. The opposite party is directed to pay Rs.67,774/- (Rupees Sixty seven Thousand seven Hundred and seventy four only) to the complainant towards the treatment expenses and Rs.5,000/- (Rupees Five Thousand only) as compensation for physical and mental agony and Rs.1,000/- (Rupees One Thousand only) towards cost of the proceeding within 30 days from the date of this order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 8th day of November 2019.
Date of Filing: 15.07.2017.
PRESIDENT :Sd/-
MEMBER :Sd/-
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APPENDIX.
Witness for the complainant:-
PW1. Byju Thomas. Manager, Kuruva Island.
Witness for the Opposite Parties:-
OPW1. Manu Mohan. Assistant Manager, Star Health.
Exhibits for the complainant:
A1. Copy of Family Health Optima Insurance Plan.
A2. Copy of Discharge Summary.
A3. Copy of In-patient Bill from KIMS Al Shifa. Dt:20.02.2017.
A4. Copy of Medicine Sale Bill. Dt:15.02.2017.
A5. Copy of Repudiation Letter. Dt:14.03.2017.
A6. Copy of Repudiation Letter. Dt:29.04.2017.
A7. Copy of Lawyer Notice. Dt:03.06.2017
X1(1). Claim Form.
X1(2). Discharge Bill. Dt:16.02.2017.
X1(3). IP Advance Receipt. Dt:16.02.2017.
X1(4). Receipt. Dt:15.02.2017.
X1(5). Medicine Sale Bill. Dt:15.02.2017.
X1(6). Medicine Sale Bill. Dt:15.02.2017.
X1(7). OP Visit Receipt. Dt:15.02.2017.
X1(8). Medicine Sale Bill. Dt:16.02.2017.
X1(9). Medicine Sale Bill. Dt:15.02.2017.
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X1(10). Laboratory Test Report. Dt:15.02.2017.
X1(11). Laboratory Test Report. Dt:15.02.2017.
X1(12). Laboratory Test Report. Dt:15.02.2017.
X1(13). Laboratory Test Report. Dt:16.02.2017.
X1(14). Hematology Analysis Report. Dt:15.02.2017.
X1(15). Discharge Summary.
X1(16). Claim Form Part A.
X1(17). Claim Form Part B.
X1(18). Details of Bills Claimed. Dt:20.02.2017.
X1(19). Discharge Summary from KIMS Al-Shifa.
X1(20). In-patient Bill.
X1(21). Pharmacy/Consumable Sales.
X1(22). OP Credit Bill. Dt:17.02.2017.
X1(23). Lab Report from KIMS Al-shifa.
X1(24). Lab Report from KIMS Al-shifa.
X1(25). Lab Report from KIMS Al-shifa.
X1(26). Lab Report from KIMS Al-shifa.
Exhibits for the opposite parties:-
B1. Copy of Leo Hospital Records.
B2. Copy of Family Health Optima Insurance Plan.
B3. Customer Information Sheet of Family Health Optima Insurance Plan.
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B4. Copy of Pre-Authorization Request Form.
B5. Copy of Query on Pre-Authorization. Dt:15.02.2017.
B6. Copy of Denial of Pre-Authorization for Cashless Treatment.Dt:16.02.2017.
B7. Copy of Repudiation Letter. Dt:14.03.2017.
B8. Copy of Request for Cashless Hospitalizaton for Medical Insurance Policy.
B9. Copy of Discharge Summary from KIMS Al-Shifa.
B10. Copy of Repudiation Letter. Dt:29.04.2017.
B11. Authorization Letter. Dt:03.03.2018.
PRESIDENT :Sd/-
MEMBER :Sd/
/True Copy/
Sd/-
SENIOR SUPERINTENDENT,
CDRF, WAYANAD.
