Sri. P. Satheesh Chandran Nair (President):
The complainant filed this complaint u/s.12 of the C.P. Act 1986.
2. The case of the complainant is as follows: The complainant is a holder of Medical Claim Policy vide No. 1001002814P111541730 TTK ID No. KOC-UI-S0816-000-0005707 – A was the opposite party. This policy is issued to the complainant through the second opposite party. According to the complainant, he was admitted at V.S.M. Hospital, Thattarambalam, Mavelikkara on 13-07-2015 due to abdominal pain, vomiting and difficulty in urination. He was admitted as an inpatient and discharged on 20-07-2015. It is contented that an amount of Rs.42,736/- was the bill amount for the treatment, the complainant filed proper medi-claim application before the opposite party on 24-07-15. On 25-07-2015 the opposite party repudiated the above said claim and informed this fact by a letter. The complainant subsequently approached the opposite party to settle the matter or send back to the original treatment records to the complainant, but all are invain. The act of the opposite parties are comes under unfair trade practice and deficiency in service of the opposite parties. All this act of the opposite parties caused humiliation, mental agony, hard ship etc. of the complainant. Hence the complainant file this case before this Forum for the re-imbursement for the medical bill of Rs. 42,736/-, compensation, cost etc.
3. This Forum entertained this complaint and issue notice to the opposite parties for their appearance. Opposite parties entered appearance and filed separate version.
4. The version of opposite party 1 is as follows: According to opposite party 1, the case is not maintainable before this Forum and this Forum lacks jurisdiction to entertain this claim. It is contented that this complaint had never issued any letter to Pathanamthitta office of 1st opposite party. It is further contented that the policy in question obtained through Syndicate Bank Chengannoor and the complainant underwent treatment at Tattarambalam both of them are in Alappay District. Hence it is stated that there is no jurisdiction for this Forum to try this case and it is to be dismissed.
5. The 2nd Opposite party’s version is as follows: According to 2nd opposite party the complainant is a policy holder vide policy No. 1001002814P111541730 TTK ID No. KOC-UI-S0816-000-0005707 – A and was admitted in V.S.M Hospital Thattarambalam, Mavelikkara from 13-07-15 to 20-07-15 for treatment of Prostrates, Renal Calculus etc. It is contented that this claim was repudiated by the opposite parties by the reason that under a fresh policy incepting from 01-03-15, the treatment of Prostrates, Renal Calculus etc are not payable during the first two years in terms of clause 4.3 of the said policy.
6. We peruse the complaint version and records before us and framed the following issues.
- Whether the case is maintainable before the Forum?
- Whether the opposite parties committed any deficiency in service against the complainant?
- Regarding the relief and cost?
7. The evidence of this case consists of the proof affidavit filed in lieu of chief examination and marked Ext A1 to A11. On the side of the opposite parties, they are neither cross examined PW1 nor adduced any evidence at the time of trial. Ext.A1 is the copy of policy. Ext.A2 is the copy of discharge card dated 20.07.2015. Ext.A3 is the copy of outpatient record dated 13.07.2015. Ext.A4 is the copy of bill dated 20.07.2015 for Rs.42,736/-. Ext.A5 is the copy of letter dated 28.07.2015 issued by the 1st opposite party to the complainant. Ext.A6 is the copy of letter dated 06.08.2015 issued by 2nd opposite party to the complainant. Ext.A7 is the copy of reply letter dated 18.08.2015 sent by the complainant to 2nd opposite party. Ext.A8 is the copy of repudiation letter dated 25.09.2015 sent by 1st opposite party to the complainant. Ext.A9 is the copy of the legal notice dated 27.11.2015 sent by the complainant to 1st opposite party. Ext.A10 is the copy of postal receipts. Ext.A11 is the copy of acknowledgment cards. According to PW1, he deposed that he is a consumer of opposite party in respect of the medi-claim policy issued by 1st opposite party through 2nd opposite party. PW1 further deposed that he paid the entire treatment expenses i.e., Rs. 47,236/-to the hospital concerned. He deposed that though he filed medi-claim application to the opposite party but it is repudiated on the basis of certain technical reasons. After the completion of the trial, we heard both sides in this case.
8. Point No. 1 to 3:- For the sake of convenience we would like to consider Point No. 1 to 3 together. The opposite party 1 raised a serious contention in this case to the effect that this case is not maintainable before this Forum and this Forum lacks jurisdiction to try this case. Though the opposite party raised this contention, they did not raise this contention seriously even at the time of filing version or even at the time of adducing the evidence. It is to see that the complainant is an advocate who is practicing at Pathanamthitta District Court and he is an insured of the opposite party for the medi-claim. In order to prove that he is an insured of the opposite party he produced and marked Ext.A1 the copy of the said policy. Likewise to prove the admission in the V.S.M. Hospital Tattarambalam, Mavelikkara, PW1 produced and marked Ext. A2 the medical treatment card, and to show medical bill of Rs.47,236/- the said medical bills are also produced and marked as Ext.A4 series. On 28/07/15 and on 06/08/15 two notices were issued by the 1st opposite party and 2nd opposite parties administrator VIDAL HEALTH respectively to the complainant. On the basis of this letter it is learned that the opposite party 1 forwarded all the documents to the 2nd opposite parties administrator VIDAL HEALTH in time. As per Ext.A5 and Ext.A6 these facts are proved. The TPA only requested the complainant to produce copy of Indoor case papers and treatment chart. As per Ext A7 it is seen that PW1 send a letter to opposite party 2 on 18-08-15 and in which it is stated that the hospital concerned is note that ‘cash less’ come under the provisions of the said policy and he is entitled for the interest of the above said medical bill, from the date of discharge onwards. When we look into the above evidence on records it can be inferred that the complainant PW1 is a holder of medi-claim policy of the opposite party 1 and he is filed medi-claim to the opposite party in time and filed all the necessary records required for the disbursement of said claim in time. The main questions raised by the opposite parties are with regard to the jurisdiction and maintainability of this case. It is to see that the opposite party 2 did not cross-examine PW1 and moreover made an endorsement of “No cross” on the docket portion of PW1’s proof affidavit. At this juncture, it is clear that the evidence adduced by PW1 by way of proof affidavit is unchallengeable as far as the complainant is concerned. If the opposite party 1 has any serious objection with regard to the maintainability or jurisdiction As stated above what prevent the opposite party 1 to raise that contention at the proper time. Hence we are in a position to arrive in a safe conclusion to the effect that the case is maintainable before this Forum and this Forum has having jurisdiction to try this case.
9. The next point to be considered is as whether the opposite party was committed any deficiency in service as an insured of the complainant and as a service provider of the complainant prima facie the opposite party is liable to the complainant. It is true that the opposite party 1 filed version stating that the complainant is not eligible to get any medi-claim because of the lack of jurisdiction and maintainability who filed explain the other reason for the repudiation of PW1 claim. As discussed earlier, it is pertinent to see that the opposite party has not cross-examined PW1 at the time of taking the evidence before this Forum. Hence it is clear that the evidence adduced by PW1 is unchallengeable and binding upon both the opposite parties. It is to be considered that even though opposite party 2 entered appearance before this Forum and filed their version to the effect that the reason for the repudiation of the said claim was due to the terms and condition described in clause 4.3 of the policy, opposite party 2 did not take any steps to prove this fact at the time of trial. Hence it can be inferred that opposite party 2 failed to justify the repudiation of the claim. So we are not bound to consider that contention when arriving the conclusion with regard to the repudiation.
10. When we peruse the evidence in this case it can be found that the opposite party 1 and 2 are equally and severally liable to the complainant. In the light of the evidence adduced by the complainant and the records referred above we can easily concluded that the complainant is succeeded to prove his case beyond any doubt. Therefore, we find that the complaint is allowable.
11. In the result, we pass the following orders:
- The opposite parties are directed to reimburse the medi-claim expenditure of the complainant Rs.42,736/- (Rupees Forty Two Thousand seven hundred and thirty six only) with 10% interest from the date of filing this petition onwards i.e., 01-04-15.
- The opposite parties are also directed to pay a compensation of Rs.5,000/- (Rupees Five Thousand only) to the complainant with 10% interest from the date of this order onwards.
- A cost of Rs.2,000/- (Rupees Two Thousand only) is also allowed to the complainant from the opposite parties with 10% interest from the date of order onwards.
Declared in the Open Forum on this the 30th day of August, 2016.
(Sd/-)
P. Satheesh Chandran Nair,
(President)
Smt. K.P. Padmasree (Member – I) : (Sd/-)
Smt. Sheela Jacob (Member – II) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : T.M. Venugopal
Exhibits marked on the side of the complainant:
A1 : Copy of the policy.
A2 : Copy of discharge card dated 20.07.2015.
A3 : Copy of outpatient record dated 13.07.2015.
A4 : Copy of bill dated 20.07.2015 for Rs.42,736/-.
A5 : Copy of letter dated 28.07.2015 issued by the 1st opposite party
to the complainant.
A6 : Copy of letter dated 06.08.2015 issued by 2nd opposite party
to the complainant.
A7 : Copy of reply letter dated 18.08.2015 sent by the complainant
to 2nd opposite party.
A8 : Copy of repudiation letter dated 25.09.2015 sent by 1st opposite party
to the complainant.
A9 : Copy of the legal notice dated 27.11.2015 sent by the complainant
to 1st opposite party.
A10 : Copy of postal receipts.
A11 : Copy of acknowledgment cards.
Witness examined on the side of the opposite parties: Nil.
Exhibits marked on the side of the opposite parties: Nil.
(By Order)
Copy to:- (1) Adv. T.M. Venugopal, Thekkemalayil House,
Mulakuzha.P.O, Chengannur.
(2) The Divisiional Manager, M/s United India Insurance Company,
No.1 Vettukattil Building, 3rd Floor, Jose Junction, M.G. Road,
Ernakulam, Cochin -16.
(3) M/s. Vidal Health TPA Pvt.Ltd, No. 39-4130, First Floor,
Mareena Building, M.G Road, Ravipuram,
Ernakulam, Kochin – 16.
(4) The Stock File.
