SRI. JIMMY KORAH (PRESIDENT)

Filed on 16/10/2007

            The case of the complainants is that he is the holder of a medi-claim policy and the complainant’s wife undergone treatment in KIMS., Trivandrum from 24.06.2006 to 26.06.2006 and he claims he is entitled to full refund of hospitalization expenses.   But the opposite parties rejected the claim by stating that the certificate of the doctor does not show ailment of disease.  The further contention is that treatment was not given for any ailment or illness or diseases.  Hence claim is not payable.  They stated there is no deficiency of services and hence dismissed of the complaint. 

               2.   The  complainant was examined as PW1 and Exts.A1 to A4 marked.  On the side of the opposite parties Exts.B1 to B6 marked.

4.  We have gone through the  pleadings, documents and  evidences adduced by the parties.  Since insured was a lady and she had some gynecology problems earlier.  She first visited gynecology department for back ache.   Hence she was sent to ortho consultation  and after various tests, it was diagnosed that back ache was due to fibroid uterus.  Since finding her age and blood group as ‘A’ negative which is rare group, her operation was postponed and advised to physiotherapy and oral medicines.  Here is  deficiency in service on the part of the opposite parties.

In the result,  the complainant is entitled to get claim amount of Rs.7,992.50/- (Rupees seven thousand nine hundred and ninety two and fifty paise only) with 9% interest from the date of complaint.   No order as to costs. 

            Dictated to the Confidential Asst. transcribed by her corrected to me  and pronounced in open Forum on this the 30^th day of  March, 2009.

                                                                                                Sd/- Sri. Jimmy Korah:

                                                                                                Sd/- Sri. K. Anirudhan:

                                                                                               Sd/- Smt. N. Shajitha Beevi :    

Appendix:-

Evidence of the complainant:-

PW1                -                       Thomas V. George (Witness)

Ext.A1             -                       A true copy of the terms and conditions and the services covered

                                                By the medi-claim insurance policy

Ext.A2             -                       A true copy of the claim form sent to the opposite party along with

                                                The Medical Certificate, report and bills from KIMS by the

                                                complainant

Ext.A3             -                       A true copy of the letter dated 27.7.2006 sent by the opposite party

                                                To the complainant

Ext.A4             -                       A true copy of the legal notice dated 23.8.2006.

Evidence of the opposite parties:-

Ext.B1              -                       Copy of the Policy schedule        

Ext.B2              -                       Claim form submitted by the complainant

Ext.B3              -                       Discharge Summary

Ext.B4              -                       Medical Certificate

Ext.B5              -                       Bills                    

Ext.B6              -                       Copy of the letter dated 27.7.2006

// True Copy //

                                                                                                                           By Order

                                                                                                            Senior Superintendent

To

            Complainant/Opposite parties/S.F.

Typed by:-pr/-

Compared by:-