IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA Dated this the 17th day of December, 2010. Present : Sri. Jacob Stephen (President) Smt. C. Lathika Bhai (Member) Sri. N. Premkumar (Member) C.C.No.62/08 (Filed on 19.06.2008)Between: Anil. P., Residing at Flat No.1, Helen Park, Pathanamthitta.P.O., Pin – 689 645. (By Adv. M. Sarath Chandran) ..... Complainant And: 1. M/s. New India Assurance Co. Ltd., Rep. by its Regional Manager, Regional Office, Ernakulam. 2. Divisional Manager, New India Assurance Co. Ltd., Kottayam. 3. Branch Manager, New India Assurance Co. Ltd., Pathanamthitta. (By Adv. P.D. Varghese) 4. Senior Branch Manager, LIC, Pathanamthitta. (By Adv. Somanathan Nair) ..... Opposite parties. O R D E R Sri. Jacob Stephen (President): The complaint had filed this complaint against the opposite parties for getting a relief from the Forum. 2. The complainant’s case is that he is working as a Development Officer of LIC Branch Office, Pathanamthitta. All the employees of LIC South Zone including the complainant are covered with a Group Medical Claim Policy with New India Assurance Company. The policy premium have been remitted by the complainant through the 4th opposite party branch Manager of LIC, Pathanamthitta branch. In addition to the said premium, the complainant have been paying additional premium also for enhanced medical coverage for ` 2 lakhs per annum. 3. As per the provisions of the above mentioned medi claim policy, the complainant is entitled to get medical expenses upto ` 2 lakhs per year from opposite parties 1 to 3. While so, the complainant was admitted on 23.09.2007 at Nagarjuna Ayurvedic Centre, Kalady for acute back pain and neck pain and he was treated there by Dr.Krishnan Nampoothiri and he was discharged on 13.10.2007. For the said treatment, the complainant was billed for ` 57,804. Thereafter the complainant submitted the claim for the medical expenses incurred for the treatment before the opposite parties with all relevant records, which was rejected by the opposite parties without assigning any reasons. The act of the opposite parties is deficiency in service, which caused mental agony and financial loss to the complainant. Hence this complaint for the realization of the medical expenses of ` 57,804 with 12% interest per annum along with compensation of ` 25,000 and cost from the opposite parties 1 to 3. 4. In this case, the first and 3rd opposite parties are exparte. The second and 4th opposite parties filed separate versions. 5. The main contention of the second opposite party is that the treatment of the complainant is not from a hospital as defined in the policy. The place where the complainant was treated is not an Ayurvedic Hospital. The said place is a tourist resort providing ayurvedic massages and other tourist based ayurvedic packages. Since the complainant is a resident of Pathanamthitta District and there are number of famous ayurvedic hospitals are available in Pathanamthitta District, it is not believable that the complainant went for treatment at a tourist based treatment centre at Kalady. The bills produced by the complainant for a period of 20 days ishighly exorbitant, arbitrary and baseless and is not supported scientifically. The medicines prescribed are unscientific and not necessary for the alleged disease as per the principles of Ayurveda. There is no previous consultation in any hospital before the alleged treatments at this tourist based place. The alleged hospital is an excellence award winner from the Tourism Department. Hence the claim of the complainant is suspicious and is not allowable. The non-settlement of the complainant’s claim was based on valid reasons and hence there is no deficiency of service from this opposite party and the reliefs claimed are not allowable. With the above contentions, the second opposite party prays for the dismissal of the complaint with their cost. 6. The main contentions of the 4th opposite party is that the complaint was an employee of the LIC and all the confirmed employees are covered with a Group medi claim policy with New India Assurance Company. The LIC OF India has remitted premium for all the employees and the premium is deducted monthly as per their age and basic pay. The complainant is also paying additional premium for enhanced medical coverage for ` 2 lakhs. The complainant’s medical bills for ` 57,804 was also forwarded by this opposite party to the New India Assurance Company on 29-10-2007. This opposite party is not a necessary party in this case and unnecessarily implicated in this case. With the above contentions, the fourth opposite party also prays for the dismissal of the complaint with their cost, as they have not committed any deficiency of service to the complainant. 7. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not? 8. The evidence of this case consists of the oral depositions of PW’s 1 and 2 and DW’s 1and 2 and Exts.A1 to A9 and B1 and B2. PW1 and DW1 also filed proof affidavits in lieu of their chief examination. After closure of evidence both sites where heard. 9. The Point:- The complainant’s allegation is that he is a medi-claim policy holder of New India Assurance Company Ltd. While the said policy was in force, he had undergone treatment at Nagarjuna Ayurvedic Centre, Kalady and he had incurred an expense of ` 57,804 for his treatment. The claim for the said medical expenses was repudiated by the insurance company. The repudiation of the claim by the insurance company is a deficiency in service and the complainant is entitled to get the said medical claim. 10. In order to prove the complainant’s case, the complainant filed proof affidavit in lieu of chief examination and produced certain documents. On the basis of the proof affidavit, the complainant was examined as PW1 and the documents produced were marked as Exts.A1 to A9. One witness was also examined for the complainant as PW2. Exts.A1 to A1(b) series are the salary slips of the complainant issued from LIC of India, Kottayam Division. Ext.A2 is the photocopy of the discharge summary dated 13.10.2007 issued from Nagarjuna Ayurvedic Centre, Kalady in the name of the complainant. Ext.A3 is the photocopy of the medical certificate dated 22.09.2007 issued by Dr. Krishnan Nampoothiri in the name of the complainant. Ext.A4 to A4(b) series are the medical bills issued from Nagarjuna Ayurvedic Centre, Kalady in the name of the complainant in respect of the complainant’s treatment. Ext.A5 is the copy of letter dated 17.03.2008 issued by the complainant to the Divisional Manager, LIC of India, Kottayam Division seeking permission for proceeding against New India Assurance Company in connection with the repudiation of the complainant’s claim. Ext.A6 is the letter issued by the complainant to the Chief Manager (Grievance Cell) of New India Assurance Company Ltd for settling the complainant’s claim. Ext.A7 is the copy of letter-dated 15.1.2008 sent to the Divisional Manager of LIC by the complainant for settling his claim. Ext.A8 is the photocopy of the application sent by the complainant to the Manager, New India Assurance Company Ltd., Thiruvananthapuram under Right to Information Act seeking certain information. Ext.A9 is the information furnished by the New India Assurance Company Ltd to the complainant in respect of Ext.A8 application. 11. On the other hand, the contention of the second opposite party is that Nagarjuna Ayurvedic Centre, Kalady where the complainant had undergone treatment is not a hospital as defined by the policy. The said institution is not a hospital and it is a tourist resort providing ayurvedic massages and other tourist based ayurvedic packages. Since the said institution is not a hospital, the bills issued from that institution is not allowable as per the terms and conditions of the medi-claim policy in question. Therefore, the second opposite party argued that the complainant is not entitled to get any of the reliefs prayed for in the complaint. 12. In order to prove the contention of the second opposite party, the second opposite party brought 2 witnesses and produced certain documents. The witnesses were examined as DWs.1 and 2. DW1 is the approved investigator of the second opposite party and DW2 is an Ayurvedic Doctor who is a panel doctor of the second opposite party. The documents produced were marked as Exts.B1 and B2. Ext.B1 is the Investigation Report prepared by DW1. Ext.B1 includes the report of DW1 and a series of photographs of Nagarjuna Ayurvedic Centre and brochure etc. of Nagarjuna Ayurvedic Centre. Ext.B2 is the Expert Opinion of DW2 in respect of the treatment of the complainant at Nagarjuna Ayurvedic Centre, Kalady. 13. On the basis of the contentions of the parties, the only question to be considered is whether the medical bills issued by Nagarjuna Ayurvedic Centre, Kalady can be admitted for allowing the complainant’s medi-claim policy. According to the complainant, Nagarjuna Ayurvedic Centre, Kalady is an Ayurvedic Hospital and the treatment bills issued from that hospital can be admitted for allowing the medi-claim policy, whereas the contention of the 2nd opposite party is that the said Nagarjuna Ayurvedic Centre is not an Ayurvedic Hospital. But it is only a Tourist Resort providing tourism based massages and other ayurvedic packages. On a perusal of Exts.A2, A3 and A4 series medical bills and Ext.A9 information furnished by the New India Assurance Company to the complainant under Right to Information Act shows that the Nagarjuna Ayurvedic Centre is an Ayurvedic Hospital and the services received by the complainant from that centre is no doubt, a medical treatment and the New India Assurance Co. had disbursed medi-claims to their policyholders who had undergone treatment at Nagarjuna Ayurvedic Centre, Kalady. Moreover, the oral testimonies of DWs.1 and 2 shows that Nagarjuna Ayurvedic Centre, Kalady is an Ayurvedic Hospital. The relevant portion of the oral deposition of DW1 is as follows:- “ImeSn skâdn BbqÀthZ NnInÕ \S¯p¶pv. ]e tdänepÅ rooms AhnsSbpv. GXp apdnbn Xmakn¡Wsa¶v I¼\n¡v \n_Ô\bnÃ. Ext.B1þt\msSm¸w hmZn Xmakn¨ncp¶ Øm]\¯nsâ admission registerþsâ tIm¸n Aäm¨p sNbvXn«pv. GXp cPnÌdnsâ tIm¸nbmsW¶p ImWn¡m³ aäp tcJIÄ CÃ. F¶m AXnsâ sk¡âv tImfw slUnwKv C³t]jyâv \¼À F¶mWv ImWn¨n«pÅXv”. 14. The relevant portion of the oral deposition of DW2 is as follows:- “hmZn NnInÕ tXSnb Bip]{XnbnÂ, Bip]{Xn ImWp¶Xn\v Rm³ t]mbn«pv. AXv hospital Bbncp¶p. Resortþsâ styleþ BWv. AhnsS Imcy§Ä \S¡p¶Xv. km[mcW Bip]{Xnbn ImWp¶Xnt\¡mÄ kuIcy§Ä Dv”. 15. The above said depositions of DWs.1 and 2 shows that Nagarjuna Ayurvedic Centre, Kalady is an Ayurvedic Hospital. Moreover, the information furnished by New India Assurance Company vide Ext.A9 shows that the medi claim based on the bills of Nagarjuna Ayurvedic Centre, Kalady can be admitted for medi claim. In the circumstances, we find that Nagarjuna Ayurvedic Centre, Kalady is an Ayurvedic Hospital and the services obtained by the complainant from that hospital is an ayurvedic treatment and the amount paid by the complainant to that hospital vide Exts.A4 series medical bills is the treatment expenses of the complainant. Therefore Ext.A4 series medical bills are admissible for allowing the medical claim of the complainant. Hence the repudiation of the complainant’s claim is a clear deficiency of service from the part of the 2nd opposite party. Hence this complaint can be allowed with cost and compensation against the opposite parties 1 to 3. 16. In the result, this complaint is allowed, thereby the opposite parties 1 to 3 are directed to pay ` 57,804 (Rupees Fifty Seven Thousand Eight Hundred and Four only) to the complainant with 9% interest per annum from the date of filing of this complaint along with compensation of ` 5,000 (Rupees Five Thousand only) and cost of ` 2,000 (Rupees Two Thousand only) within 30 days from the date of receipt of this order, failing which the complainant is allowed to realise the whole amount ordered herein above with an interest at the rate of 12% per annum from today till the realisation of the whole amount. Declared in the Open Forum on this the 17th day of December, 2010. (Sd/-) Jacob Stephen, (President) Smt. C. Lathika Bhai (Member) : (Sd/-) Sri. N.Premkumar (Member) : (Sd/-) Appendix: Witness examined on the side of the complainant: PW1 : Anil. P. PW2 : B. Rajasekharan Nair Exhibits marked on the side of the complainant: A1, A1(a) & A1(b) : Salary Slips (3 in number) A2 : Photocopy of the discharge summary A3 : Photocopy of the medical certificate A4 : Photocopies of the medical bills. A5 : Photocopy of the notice dated 17.3.08 issued by the complainant to the 2nd opposite party. A6 : Photocopy of the letter dated 9.5.08 issued by the complainant to the Chief Manager, Public Grievance Cell Head Office, New India Assurance Co. Ltd. Mumbai. A7 : Photocopy of the letter dated 15.1.08 sent by the complainant to the 3rd opposite party. A8 : Photocopy of the application filed under Right to Information Act. A9 : Copy of letter dated 30.9.09 issued by the Divisional Manager, Divisional Office, New India Assurance Co. Ltd., Palayam, Thiruvananthapuram to the complainant. Witness examined on the side of the opposite parties: DW1 : Binoy Augustin DW2 : K.S. Ravisankar. Exhibits marked on the side of the opposite parties: B1 : Investigation Report on medi-claim B2 : Expert opinion. (By Order) Senior Superintendent. Copy to:- (1) Anil. P., Residing at Flat No.1, Helen Park, Pathanamthitta.P.O., Pin – 689 645. (2) Regional Manager, M/s. New India Assurance Co. Ltd., Regional Office, Ernakulam. (3) Divisional Manager, New India Assurance Co. Ltd., Kottayam. (4) Branch Manager, New India Assurance Co. Ltd., Pathanamthitta. (5) Senior Branch Manager, LIC, Pathanamthitta. (6) The Stock File. | 
