By. Sri. Jose. V. Thannikode, President:
The complaint is filed under section 12 of the Consumer Protection Act against the opposite party to get the medical expenses incurred in the treatment which she is entitled under the insurance policy and to get cost and compensation due to non allowing the claim.
2. Brief of the complaint:- The complainant taken the Max Bupa Health Insurance Policy from opposite party as policy No.00201900201400 and the policy certificate is issued to the complainant on 22.01.2015. Two lakhs was the sum assured and the complainant paid the premium also. On 23.05.2015 complainant's knee replaced from Ganga Medical Center and Hospital (P) limited, Mettupalayam, Coimbatore after surgery on the advice of Doctor on a pain in the leg. For that treatment the complainant spend Rs.1,70,774/-. Thereafter the complainant's claim application and connected documents and bills were given to the opposite party, but the opposite party has return back all the documents and claim form without saying any reason and also not given any letter to repudiate the claim. The complainant could not know the reason why the opposite party has return back the claim form and documents. The opposite party is liable to pay all the treatment expenses below 2 lakhs as per the terms and conditions of the policy. The return back of the claim file with documents and not giving the claim amount till today is a gross deficiency of service and unfair trade practice from the side of opposite party. The cause of action arose on 07.07.2015, when the opposite party has return back the claim form and when it is received from the Branch office at Sulthan Bathery. Hence prayed before the Forum to direct the opposite party to pay the claim amount of Rs.1,70,774/- and to pay Rs.5,000/- for the difficulties caused and other relief as the Forum deems fit to grand.
3. Notice were served to opposite party on 11.09.2015 but not appeared before the Forum and not filed version also. Hence they set ex-parte.
4. Complainant filed proof affidavit and stated as stated in the complaint and further stated that the claim application and documents were send to opposite party through there Sulthan Bathery branch office and opposite party returned the same through Sulthan Bathery branch office and she is examined as PW1 and Ext.A1 to A7 documents were marked. Ext.A1 is the Certificate of Insurance (Group Health Insurance), in which it is written the Max Bupa Health Insurance and Policy No.00201900201400 and policy holders name is Muthoot Finance Limited and the policy issue date is 22.01.2015 risk inception date and time 27.02.2015 12.00 AM, Risk Expiry dated and time 26.02.2016 11.59 PM, sum assured is Rs.2,00,000/- and premium amount is Rs.2,200/-. Ext.A2 is the Discharge summary wherein the name of the patient is Ponnamma. K. K, and she was admitted on 21.05.2015 and discharged on 29.05.2015. The diagnosis was BILATERAL OSTEOARTHRITIS KNEE WITH VARUS DEFORMITY, DIABETES MELLITUS, HYPERTENSION. Procedure:- 23.05.2015 Total Knee Replacement Right Side. Ext.A3 series 1 to 26 is the bills for Rs.1,70,774/- issued by Ganga medical Centre and Hospital Pvt Ltd. Ext.A3(27) is the letter given by Muthoot Insurance Brockers (p) Ltd, Kannur to Sulthan Bathery Muthoot Group, wherein it is stated that the formalities and required documents to be produced for claim. Ext.A3(28) is the Claim form given by the complainant to opposite party dated 30.05.2015. Ext.A4 is the Membership, customer Identity card issued to complainant by Max Bupa health insurance valid from 27.02.2015. Ext.A5 is the cover in which the Jipsy. M. P, Muthoot Insurance Brockers (p) ltd, Kannur has returned back the claim form and connected document to the complainant through their Bathery office address ie “Muthoot Finance Ltd, Thenungal Building, Near Seena Theatre, Chulliyode road, Sulthan Bathery, wherein Max Bupa is also written”. Ext.A6 is the courier receipt of professional courier of Sulthan Bathery it shows that one letter send from Muthoot Finance Sulthan Bathery to Muthoot Finance (RO) Kannur, in which the claim application with all document is sent. Ext.A7 is the receipt issued by the Branch Office of the opposite party ie Muthoot Finance Sulthan Bathery dated 25.02.2015 for receipt of Rs.2,200/- as premium.
5. On perusal of complaint, affidavit and documents the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the side of opposite party?
2. Relief and cost.
6. Point No.1:- The Ext.A6 shows that the premium is collected by the opposite party and opposite party has issued the policy certificate also for coverage up to Rs.2 lakh for treatment for the period 27.02.2015 to 26.02.2016 in between the period the complainant availed treatment and Ext.A2 discharge summary of hospital proves the illness and treatment, Ext.A4 shows that the complainant is holding a health insurance ID card issued by the opposite party and Ext.A5 shows that opposite party has received the claim application and return back to the complainant through their branch and Ext.A3(27) and Ext.A3(28) proves that the complainant filed claim application and it is returned back by the opposite party without considering the claim. It shows the present address of opposite party. Hence we opine that not considering the claim application and not allowing the claim by the opposite party is a clear deficiency of service and unfair trade practice from the side of opposite party and the Point No.1 is found accordingly.
7. Point No.2:- Since the Point No.1 is found is against the opposite party, opposite party is liable to pay the treatment expenses, cost and compensation to the complainant and the complainant is entitled for the same.
In the result, the complaint is partly allowed and the opposite party is directed to pay Rs.1,70,774/- (Rupees One Lakh Seventy Thousand Seven Hundred and Seventy Four) towards the treatment expenses and Rs.5,000/- (Rupees Five Thousand) as cost and compensation to the complainant within 30 days from the date of receipt of this Order, failing which the complainant is entitled for an interest at the rate of 12% per annum till payment.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 12th day of October 2015.
Date of Filing:06.08.2015.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Ponnamma. K. K.(Affidavit). Complainant.
Witness for the Opposite Party:-
Nil.
Exhibits for the complainant:
A1. Certificate of Insurance.
A2. Copy of Discharge Summary.
A3(Series 1 to 26). Medical Bills and Receipts.
A3(27). Letter.
A3(28). Claim Form.
A4. Membership and Customer Identity Card.
A5. Letter Cover.
A6. Courier Receipt. Dt:05.06.2015.
A7. Receipt Voucher. Dt:25.02.2015.
Exhibits for the opposite party:-
Nil.
Sd/-
PRESIDENT, CDRF, WAYANAD.
a/-
