CONSUMER DISPUTES REDRESSAL FORUM

PALAKKAD, KERALA

Dated this the 22^nd day of December, 2012.

Present: Smt. Seena. H, President

: Smt. Preetha. G. Nair, Member

: Smt. Bhanumathi. A.K, Member Date of filing: 11/04/2012

CC /63/2012

George Tom,

S/o. Tom George, residing at - Complainant

Kizhakkeparambil house,

Chittady P.O., Alathur Taluk,

Palakkad District, Rep by his father

Tom George.

(BY ADV. M.P. Ravi)

Vs

1. M/s. Reliance Life Insurance Co. Ltd.,

Regd. Office, Hest Block, 1^st Floor,

Thiruvashai, Ambani Knowledge City, - Opposite parties

Navi Mumbai, Maharashtra – 400 710

(By Adv. N. Rajesh)

2. M/s. Medi Assist India TPA Private Limited,

Shilpa Vidya, 3^rd Floor, # 49, 1^st Main Road,

Sarakki Industrial Layout, 3^rd Stage, J.P. Nagar,

Bangalore – 560 078.

3. M/s. Reliance Life Insurance Co. Ltd.,

Mangalam Towers, T.B. Road, Palakkad.

( By Adv. Ullas Sudhakaran)

4. Reliance Life Insurance Co. Ltd.,

Century plaza, Tharekkad, Palakkad.

O R D E R

BY SMT. BHANUMATHI. A.K, MEMBER

Case of the complaint is as follows :-

The complainant is represented by his father since he is completely bed ridden and physically disabled and unable to speak or sign. The complainant has availed a medi claim policy issued by the 1^st opposite party as per policy No. 13864234 under the name Reliance Life Insurance Wealth+ Health plan. The complainant met with an accident on 7/11/2009 and he has undergone treatment at Jubilee Mission Medical college Hospital, Thrissur. He had earlier submitted a claim with 1^st opposite party which was processed by the 2^nd opposite party. The said claim settled by the opposite party for Rs. 1,50,000/- as per letter dtd. 29/09/2010.

Later the complainant continued his treatment and has undergone physiotherapy as advised by the doctors. He has undergone Ayurvedic treatment also because of the fact that the nature of injuries sustained by him requires such treatments. These treatments were done as advised by the doctors who had treated him earlier. Now the complainant is not in a position to speak or walk and he is having permanent disability of more than 50%. The complainant is continuing his treatment. Subsequently the complainant submitted a claim with the opposite party as claim No. RLIC 4373 which was repudiated as per letter dtd. 24/09/2011. Another claim as claim No. RLIC 4641 also repudiated by the opposite party as per letter dtd. 10/01/2012. The reason stated for repudiating the claim is not correct. After collecting huge amounts from the complainant, the opposite party is repudiating the claim on false grounds.

The act of opposite parties amounts to clear deficiency of service on their part. So the complainant seeking an order directing the opposite parties to pay the claim amounts of Rs. 1,18,403/- and Rs. 1,00,000/- and Rs. 50.000/- towards compensation for mental agony and cost of the proceedings to the complainant.

1^st and 3^rd opposite parties entered appearance and filed version. 2^nd and 4^th opposite parties set exparte.

1^st opposite party admits the policy availed by the complainant. 1^st opposite party aslo admits that earlier the complainant submitted a claim No. RLIC /3135 dtd. 29/09/2010 was settled by the opposite party. 1^st opposite party denies that the complainant is more than 50% permanent disabled and still any kind of further treatment is going on or necessary.

Opposite party has repudiated the claims dtd. 10/01/2012 on the ground that the said policy covers the claim only for Allopathic treatment but the complainant was under going for Ayurvedic treatment. Ayurvedic treatment cannot be covered under the said policy. These is no deficiency of service on the part of opposite party 1 and complainant is liable to be dismissed with cost.

In their version Supplemental 3^rd opposite party submits that the address of Supplemental opposite party 3 shown in the cause title is not the address of Reliance Life Insurance Company Ltd. and it is the address of the branch office of Reliance General Insurance Company Ltd. and the branch of Reliance Life Insurance Company is not situated in the said address. Reliance General Insurance Company has no connection with the 1^st and 2^nd opposite parties and the Health Policy claimed to have been taken by the complainant from the 1^st and 2^nd opposite parties. Reliance General Insurance Company has nothing to do with the alleged grievance of the complainant and hence RGICL is legally entitled to get deleted from the party array.

Complainant and 3^rd opposite party filed their respective affidavits. Ext. A1 to A5 marked on the side of the complainant. 1^st Opposite party has not filed any affidavit.

Heard both parties.

Issues to be considered are

1. Whether there is any deficiency of service on the part of opposite parties ?

2. If so what is the relief and cost?

    

Issues I & II

Complainant has availed a medi claim policy issued by 1^st opposite party as per policy No. 13864234 under the name Reliance Life Insurance Wealth + Health plan. The complainant met with an accident on 7/11/2009 and caused 60% permanent neurological disability. It is evident from Ext.A4 document. Earlier the complainant had submitted a claim to the 1^st opposite party which was processed by 2^nd opposite party and settled by the opposite party for Rs. 1,50,000/-. Ext. A1 shows the same. Later the complainant continued his treatment and has undergone physiotherapy as advised by the doctors. Further the complainant has undergone Ayurvedic treatment aslo because of the fact that the nature of injuries sustained by him requires such treatments. These treatments were done as advised by the doctors who had treated him earlier. Subsequently the complainant submitted two claims with the opposite party. The claim No. RLIC 4373 was repudiated by opposite party as per letter dtd. 24/09/2011. That is marked as Ext. A2. The reason stated for repudiation in Exclusion No. 5 : Clause 16 : Hospitalisation for the sole purpose of physiotherapy or any ailment for which hospitalisation is not warranted due to advancement in medical technology. But in this case the complainant has become completely bed ridden. Ext. A4 document, Disability certificate, shows that the complainant is assessed to have 60% permanent neurological disability. So it is clear that the hospitalisation of the complainant is very essential. So the opposite party is liable to pay the claim amount as per the claim No. 4373 to the complainant. In the complaint the claim amount is written as Rs. 1,18,403/-. As per Ext. A3 document claim No.RLIC /4641 also repudiated stating the treatment has been availed at an Ayurvedic Hospital. The policy covers only Allopathic system of medicine ie. clause : 5 : Exclusion No. 22. It is true that such patients needed some Ayurvedic treatment after the Allopathic treatment. But the policy covers only Allopathic system of treatment.

From the above discussions we are of the view that there is deficiency of service on the part of opposite parties.

In the result complaint partly allowed. Opposite parties 1,2,&4 are jointly and severally directed to pay an amount of Rs. 1,18,403/- ( Rupees One lakh Eighteen thousand Four hundred and three only) as the claim amount and Rs. 5,000/- (Rupees Five thousand only) as compensation and Rs. 1,000/- ( Rupees One thousand only) as cost of the proceedings. Opposite party 3 is exonerated from the liabilities.

Order shall be complied within one month from the date of receipt of order, failing which the complainant is entitled for 9% interest per annum for the whole amount from the date of order till realization.

Pronounced in the open court on this the 22^nd day of December, 2012

Sd/-

Smt. Seena. H

President

Sd/-

Smt. Preetha.G.Nair

Member

Sd/-

Smt. Bhanumathi.A.K

Member

A P P E N D I X

Exhibits marked on the side of complainant

Ext. A1– Claim settlement letter issued by the opposite party to the complainant dtd.29/09/10.

Ext. A2- Claim denial letter issued by the opposite party to the complainant dtd. 24/09/11

Ext. A3- Claim denial letter issued by the opposite party to the complainant dtd. 10/01/12

Ext A4- Copy of Disability certificate issued by Dr. Shaji Abraham to the complainant dtd. 09/11/11

Ext. A5- Copy of policy.

Exhibits marked on the side of opposite party

Nil

Witness examined on the side of complainant

Nil

Witness examined on the side of opposite party

Nil

Cost allowed

Rs. 1000/- (One Thousand only )allowed as cost of the proceedings.