O R D E R

Smt. K.P. Padmasree (Member - I):

                   Complainant filed this complaint against the opposite parties u/s.12 of the C.P. Act to get a relief from the Forum. 

                   2. Brief facts of the case is as follows: 1^st opposite party is an Insurance Co. and the 2^nd opposite party is the agent of 1^st opposite party.  Complainant is a senior citizen who was holding continuous Hospitalization Benefit policies with the 1^st opposite party since 2002.  For the year 2013-2014 complainant had valid policy coverage vide policy No.571402/48/13/850000503 for the period from 05.07.2013 to 04.07.2014.

                   3. During the period of said policy, the complainant had admitted as inpatient at Medical Trust Hospital, Kulanada from 17.08.2013 to 24.08.2014.  Complainant had spend Rs.21,207/- towards his treatment expenses inclusive of pre and post hospitalization expenses for the said period.  After discharge from hospital complainant lodged a claim along with all relevant documents before the opposite parties on 05.05.2014 for the reimbursement of the said amount.  Even the opposite parties had to settle the claim within 30 days of the receipt of the same they deliberately withheld the documents citing lame reasons.

                   4. On 03.09.2014 complainant send a legal notice to the opposite parties for settling the claim.  But the opposite parties did not settle the claim even after the receipt of the notice.  1^st opposite party issued a reply notice to the complainant’s lawyer, alleging that non-settlement of the claim was for want of certain documents.  It is also stated that they had sent 3 letters to the complainant seeking certain documents.  But the complainant had never received any of such letters from the 1^st opposite party.

                   5. Therefore, the inordinate delay in settling the claim by the opposite parties is a clear deficiency in service which caused financial loss and mental agony to the complainant.  Hence this complainant for getting the total claim of Rs.21,207/- along with cost and compensation. 

                   6. In this case 1^st opposite party entered appearance and filed their version and 2^nd opposite party set exparte.

                   7. 1^st opposite party filed version with the following contentions:  1^st opposite party admit that they had issued a Mediclaim Insurance policy in the name of the complainant and his family for a period from 05.07.2013 to 04.07.2014.  Complainant lodged a claim for Rs.20,127/- before the 1^st opposite party and the 1^st opposite party forwarded the claim documents to the 2^nd opposite party, who is the TPA of the 1^st opposite party.  After scrutiny of the records the 2^nd opposite party requested the complainant vide letter dated 03.06.2014 to provide – break up for medicines and service charges of Rs.5,520/- laboratory report of Rs.785/- dated 14.08.2013 and bank account details.  As there was no response from the complainant, the 2^nd opposite party send 2 reminder letters to the complainant.  But there is no response from the side of the complainant.  The settlement of the claim was delayed only because of non-submission of the above said documents.  Moreover, the opposite parties so far didn’t repudiate the claim of the complainant as such there is no deficiency in service on the part of the opposite parties.  With the above contention, 1^st opposite party prays for the dismissal of the complaint with their cost.

                   8. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?

                   9. The evidence of this complaint consists of the oral testimony of PW1, Ext.A1 to A9 and Ext.B1.  After closure of evidence, both sides were heard and opposite party filed argument notes. 

                   10. The Point:-  Complainant’s case is that he had joined an insurance policy of the opposite parties since 2002.  During the pendency of the said policy, the complainant had admitted as inpatient at Medical Trust Hospital, Kulanada from 17.08.2013 to 24.08.2014.  The treatment expense is Rs.27,207/-, and the complainant submitted the claim before the opposite parties with all documents required.  But the opposite parties deliberately withheld the documents citing lame excuses.  Complainant send legal notice.  But the 1^st opposite party send reply notice with certain allegations.  Therefore, the inordinate delay committed by the opposite parties in settling the claim and disbursing the amount in due time is a gross deficiency in service from their part and hence opposite parties are liable to the complainant for the same. 

                   11. In order to prove the case of the complainant, complainant filed proof affidavit along with 9 documents.  Documents were marked as Ext.A1 to A9.  Ext.A1 is the claim form dated 05.05.2014.  Ext.A2 is the Medical Certificate issued by Dr. Vijayakumar dated 05.05.2014.  Ext.A3 is the discharge summary from Medical Trust Hospital.  Ext.A4 is the cash bill of Rs.10,410/- dated 24.08.2013.  Ext.A5 series are the medical bills of Medical Trust Hospital.  Ext.A6 is the medical certificate showing the break up particulars of Rs.20,106/-.  Ext.A7 is the office copy of legal notice issued by the complainant to the opposite parties dated 03.09.2014.  Ext.A8 is the reply notice issued by the 1^st opposite party to the complainant’s counsel.  Ext.A9 is the cash bill voucher of Rs.10,000/- issued by complainant’s counsel Adv. V.O. Robinson.

                   12. On the other hand, the contention of the 1^st opposite party is that they had issued the policy to the complainant.  Complainant had claimed an amount of Rs.20,127/- as the expenses incurred for his treatment.  After scrutiny of the records the complainant was requested to provide certain documents.  There was no response from the complainant, opposite party again sent reminders.  But complainant did not turned up.  Opposite parties did not repudiate the claim of the complainant so far.  Hence there is no deficiency in service from the 1^st opposite party.

                   13. In order to prove the case of the opposite party, there is no oral evidence from their side.  Opposite parties counsel cross-examined the complainant and marked Ext.B1 document.

                   14. On the basis of the contentions and arguments of the parties, it is seen that the parties have no dispute with regard to the policy in question and the subsequent treatment in the policy period.  The only dispute is with regard to the bifurcation of Rs.5,520/-.  According to the complainant, they have submitted all the necessary documents along with the claim form.  Moreover, he did not get any reminder letter from the opposite party seeking clarification.  In his deposition PW1 deposed, “എനിയ്ക്ക് കന്പനി യാതൊരു  communicationþനും നാളിതുവരെ ലഭിച്ചിട്ടില്ല ……….ഈ notice (Ext.B1) ലഭിച്ചത് ഞാൻ advocateþനെ കണ്ട് case file ചെയ്ത ശേഷമാണ്”.  But the opposite parties contention is that they have send letters to the complainant for clarification, but the complainant not turned up.  For establishing the contention they relied on Ext.B1 document.  It is the acknowledgment card signed by the complainant on 11.11.2014. 

                   15. The main dispute is with regard to the bifurcation of Rs.5,520/-. As per Ext.A6(a) we can calculate the bifurcation of Rs.5,520/-.  It is seen that the complainant issued a legal notice Ext.A7 on 03.09.2014 and the complainant received Ext.B1 A/d card on 11.11.2014.  So it is clear that the 1^st opposite party sent a letter to the complainant only after he initiated the legal proceedings against the opposite party.  The next question to be considered is whether the expenses shown in Ext.A6(a) made any ambiguity to 1^st opposite party.  When PW1 is examined before this Forum in re-examination he deposed that, “Ext.A6(a) ൻറെ 551.60 മുതല് 25.00 എന്നു കാണുന്ന ഭാഗം വരെ total ചെയ്താല് 4,420/þ രൂപയും , 4þmw പേജിലെ service charge 700/þ രൂപയും linen and electric charge 700/þ രൂപയും കൂട്ടിയാല് 5,520/þ രൂപയാണ് എന്ന് വ്യക്തമാകും”.  We do admit that this bifurcation can be traced out only by PW1.  A plain reading of Ext.A6(a) could not reveal this details.  We have to bear in mind that the definite case of PW1 is that 1^st opposite party has not send any letter stating the reason for the withholding of his document or reason for the delay of the disbursement of the claim amount.  As stated earlier it is proved that 1^st opposite party has send a letter to PW1 and the same was accepted by PW1 on 11.11.2014 as per Ext.B1.  At the same time, it is interesting to see that 1^st opposite party failed to produce the office copy of that letter or contents of the said alleged letter on the basis of the Ext.B1 Acknowledgment card.  Hence regarding the contents of this letter no convincing evidence is before us.  If the contents of the letter was connected to the bifurcation of the said amount or for calling of sufficient records, we have to believe the stands taken by the 1^st opposite party in this case is more probable.  But at the same time, Ext.A8 dated 10.09.2014 is seen issued by 1^st opposite party in favour of the counsel for the complainant.  In that letter (Ext.A8),

(1) Please provide break up for medicine and service charge Rs.5,520/-

(2) Please provide lab report of Rs.785/- dated 14.08.2013.

(3) Please provide Bank Account details such as Name of the Account  

     Holder, Account Number., Bank Branch, IFSC Code, Account Type  

     (Account Holder should be the Primary beneficiary or the Employee), 

     Enclose cancelled cheque of the Account Holder.

As far as Ext.A8 is concerned the contents of this letter is binding to PW1 even though it is an information to his counsel Adv. V.O. Robinson.  In Ext.A8, it reveals that 1^st opposite party issued 3 letters to PW1 on 3^rd June, 14^th June and 23^rd June 2014.  Except the narration of the 3 days in Ext.A8 1^st opposite party is not succeed to prove the delivery of the letters to the complainant.  As a reputed company 1^st opposite party is liable to prove that facts before this Forum but due to unknown reasons that also did not disclose before us.  It is also not justifiable on the part of 1^st opposite party to withhold the disbursement of the claim without any proper or valid ground.  It is pertinent to see that Ext.A8 notice is an after thought by receiving the legal notice Ext.A7.

                   16. When we look into the evidence of this case, we can come to a conclusion that 1^st opposite party simply drag the matter without any sufficient reasons.  Though the complainant requested to allow compensation of Rs.10,000/- and litigation cost of Rs.10,000/- apart from the above said claim amount we do not fully agreed with this request considering the nature and circumstances of this case.

                   17. In the circumstances stated above, we find that the 1^st opposite party caused inordinate delay in the disbursement of the claim of the complainant and the 1^st opposite party is liable to answer for it.  The act of 1^st opposite party is a clear deficiency in service.  Though the 2^nd opposite party is a party in this case no evidence is adduced against him to prove any deficiency in service etc on his part.  Hence we decided to exonerate 2^nd opposite party from all allegations.  Hence the Point found in favour of the complainant. 

                   18. In the result, we pass the following orders:-

1. 1^st opposite party is directed to pay an insurance claim amount of Rs.21,207/- (Rupees Twenty one Thousand Two hundred and seven only) to the complainant from the date of application, i.e. 05.05.2014 along with 10% interest till its realization.

2. The 1^st opposite party is directed to pay a compensation of Rs.10,000/- (Rupees Ten Thousand only) to the complainant with interest of 10% till its realization from the date of receipt of this order.
3. A cost of Rs.3,000/- (Rupees Three Thousand only) is also allowed to the complainant with an interest of 10% till the date of realization from the date of receipt of this order.  (If the 1^st opposite party pay the amount within 1 month of the date of receipt of this order, opposite party need not pay the interest mentioned above). 

                   Declared in the Open Forum on this the 21^st day of August, 2015.

                                                                                                        (Sd/-)

                                                                                               K.P. Padmasree

                                                                                                  (Member – 1)

Sri. P. Satheesh  Chandran Nair (President)         :    (Sd/-)

Smt. Sheela Jacob (Member – II)                          :    (Sd/-)

Appendix:

Witness examined on the side of the complainant:

PW1  :  P.K. Mathew

Exhibits marked on the side of the complainant:

A1 :  Claim form dated 05.05.2014 issued by the 2^nd opposite party in the

        name of the complainant. 

A2 :  Medical Certificate issued by Dr. Vijayakumar dated 05.05.2014. 

A3 :  Discharge Summary from Medical Trust Hospital. 

A4 :  Cash bill dated 24.08.2013 of Rs.10,410/-. 

A5 series :  Medical bills of Medical Trust Hospital. 

A6 series :  Medical certificate showing the break up particulars of Rs.20,106/-. 

A7 :  Office copy of legal notice dated 03.09.2014 issued by the complainant

        to the opposite parties.   

A8 :  Reply notice dated 10.09.2014 issued by the 1^st opposite party

        to the complainant’s counsel. 

A9 :  Cash bill voucher dated 14.01.2015 of Rs.10,000/- issued by

        complainant’s counsel Adv. V.O. Robinson. 

Witness examined on the side of the opposite parties:  Nil.

Exhibits marked on the side of the opposite parties:

B1  :   Acknowledgment card.

                                                                                                   (By Order)

Copy to:- (1) P.K. Mathew, Melekoottu HoO R D E R

Sri. P. Satheesh Chandran Nair (President)

                   Case advanced by opposite party and filed compromise petition signed by complainant and opposite party.  Case disposed as per the terms of compromise. 

                  Declared in the Open Forum on this the 25^th day of August, 2015.

                                                                                                    (Sd/-)

                                                                                    P. Satheesh Chandran Nair,

                                                                                                                       (President)

Smt. Sheela Jacob (Member – II)                 :   (Sd/-)

Appendix  -  Nil.

                                                                                                                         (By Order)

                                                                                                  (Sd/-)

Copy to:- (1) Appoos Vallikkala, (All Kerala Human Protection Army State 

                    President), 1^st Floor, Panamparampil Buildings,

                    Opp. Perumpuzha Bus Stand, Ranni, Pathanamthitta – 689 672.                 (2)  The Secretary, Cherukole Service Co-op: Bank Ltd.,

                    Cherukol.P.O., Vazhakkunnam (Via), Kozhencherry.

               (3) The Stock File.

use, Nannuvakkadu,

                    Pathanamthitta.

2. Branch Manager, M/s. National Insurance Co. Ltd.,

           Pathanamthitta.

3.  M/s. Medi Assist India TPA Pvt. Ltd., Shilpa Vidhya, 3^rd Floor,

      H 49, 1^st Main Road, Sarakki, Industrial Layout,

           3^rd Phase, J.P. Nagar, Bangalore – 560 078.

      (4) The Stock File.