Kerala

Idukki

CC/199/2019

T K Jagadeesh - Complainant(s)

Versus

National insurance co ltd - Opp.Party(s)

30 Mar 2023

ORDER

DATE OF FILING : 13/11/2019

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the 30^th  day of  March 2023

Present :

              SRI.C.SURESHKUMAR                                               PRESIDENT

              SMT.ASAMOL P.                                                          MEMBER

              SRI.AMPADY K.S.                                                        MEMBER

CC NO.199/2019

Between

Complainant                          :  1 . T.K.Jagadeesh Prathap,

                                                       Thayyakodathu House,

                                                       Thodupuzha East P.O., Thodupuzha,

                                                        Idukki District – 685 585.

                                                  2 .  Smt.Beena Jagadeesh, W/o Jagadeesh,

                                                        Thayyakodathu House,

                                                        Thodupuzha East P.O., Thodupuzha,

                                                         Idukki District – 685 585.

                                                           And

Opposite Party                 :   1 . National Insurance Co.Ltd.,

                                                  Represented by Branch Manager,

                                                  1^st Floor, Pulimoottil Shopping Arcade,

                                                  Thodupuzha, Idukki District, Pin – 685 584.

                                              2 . Medi Assist India Pvt.Ltd.,

                                                   Chicago Plaza 4^th Floor, Rajaji Road,

                                                    Opposite M.G.Road, Ernakulam – 682 035.    

                                                   (Both by Adv.Berg George

O R D E R

SRI.AMPADY K.S., MEMBER

 

This complaint was filed Under Section 12 of Consumer Protection Act, 1986 raising the following allegations against opposite parties.

1 . First complainant was holding Mediclaim Policy No.570801/48/17/8500000148 for the period from 09/05/2017 to 08/05/2018

(Cont......2)

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under 1^st opposite party.  2^nd complainant is the wife of 1^st complainant and both of them along with their son Swaroop J Prathap also under the mediclaim benefit under the above policy worth Rs.50,000/- each.  Petitioners were holding mediclaim policy under the 1^st opposite party from 2002 onwards too.  The 2^nd opposite party is the TPA appointed and arranged by the 1^st opposite party for the settlement of their mediclaim.

2 .  2^nd complainant sustained severe injuries in a motor vehicle accident occurred at Thodupuzha on 11/11/2017 and she was treated at Chazhikkattu Hospital, Thodupuzha and thereafter she was admitted and treated at Warrier Dispensary Kumaramangalam, Thodupzha from 22/11/2017 to 05/12/2017 as she was not completely restored in to  health and injuries by former treatment.  Dr.R.R.B. Warrier is an A Class practitioner of Indian System of Medicine who treated the 2^nd complainant Abhighataja Roga in the form of severe body pain, morning stiffness, swelling all over the body, scalp odema, vertigo and giddiness etc., and she was advised to under three months bed rest and also advised to continue the treatment.   Rs.35,000/- was spent for the above treatment.  Complainants were given only Rs.4000/- towards the treatment being the mediclaim and opposite party summarily denied claim made by the petitioners for the amount for the treatment under the Indian System of Medicine as stated above, which is a gross violation of policy terms and conditions and opposite parties are duly bound to disburse the claim made by the petitioners.  Only Rs.4000/- was allowed towards the medicalim for the treatment availed from the Chazhikkattu Hospital for the injury sustained to the 2^nd complainant under the above mediclaim policy.

3 . Rs.35,000/- were incurred for the medical expenses towards the treatment of 2^nd complainant under Indian System of Medicine along with Rs.45,000/- towards the bystander expense and associated expense.  Since  

(Cont......3)

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the Mediclaim was made under valid current policy, the opposite party cannot refuse the claim and the stand taken by the insurer and its T.P.A is illegal, arbitrary and severe negligent, resulting in deficiency of service from their part.  As per the terms and conditions of policy up to Rs.1,00,000/- is entitled towards the medicalim and opposite parties cannot deny a genuine claim.  Complainants have placed claim application before the opposite parties along with necessary document in time and also provided supplementary details too on their demand.  But the claim was rejected without assigning any sustainable reason.  Opposite parties are bound to act satisfying the claim of complainants as the mediclaim assured in favour of a policy holder is not a favour or offer from the part of insurer but it is  a right of the policy holder and beneficiary.  There is no legal or other impediments for allowing the mediclaim made by  complainants.  There is no stipulation or condition in the policy for rejecting the claim  for treatment under Indian System of Medicine too.  The treatment was availed from a reputed and government approved senior medical practitioner.  Moreover, the treatment availed is strictly in accordance with the health problem faced by the 2^nd complainant caused in the motor accident.  Allopathical treatment was not enough and effective for her satisfactory relief from the injuries, which compelled to approach for further treatment under Indian System of Medicine.  Complainants are also entitled for the compensation from the opposite party for the service deficiency from their part and the  cost of this proceedings.  2^nd complainant was unable to stand and walk for more than three  months and who was attended by a bystander all along that time and more than Rs.45,000/- incurred for the same.  Therefore complainants are entitled for Rs.35,000/- towards medical expense Rs.45,000/- towards bystander cost and Rs.25,000/- towards the compensation and proceedings cost respectively and Hon’ble Forum may kindly be pleased to allow the above claim and prayed accordingly.

(Cont......4)

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Opposite parties 1 and 2 filed joint written version on the following lines.

1 . The complaint is not maintainable either in law or on facts. The complainants have no cause of action against these opposite parties.

2 . It is true that the 1^st complainant is a policy holder of ‘National Mediclaim Policy’ for a period  from 09/05/2017 to 08/05/2018 vide Policy No.57080148178500000148.  However the policy is subject to the terms, definitions, exclusions and conditions contained in it.  A copy of certificate of Insurance and National Medicalim policy, issued to the 1^st complainant are produced herewith.

3 . Condition 5.15 of the National Mediclaim policy is extracted here.  ‘If the company shall disclaim liability to the insured person for any claim hereunder and if the insured person shall not within 12 calendar months from the date  of receipt of the notice of such disclaimer notify the company in writing that he does not accept such disclaimer and intends to recover his claim from the company, then the claim shall for all purposes to be deemed to have been  abandoned and shall not thereafter be recoverable hereunder’.  Here, the complainants had not given any notice in writing to the 1^st opposite party regarding the non acceptance of disclaimer and his intention to recover his claim from the company.  Hence, the claim of the complainant shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable.  Thus the complaint is liable to be dismissed.  Besides, there was no deficiency of service on the part of these opposite parties and thus the petition is not maintainable.

4 . The averments made in paragraph 2 and 3 are not fully true and hence denied.  The averment in the complaint that the opposite parties rejected the claim of the complainant without assigning any sustainable

(Cont......5)

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reason is false and hence denied.  It is humbly submitted that the claim of the complainants were not summarily rejected.  The 1^st complainant had applied for re imbursement of the treatment expenses for Rs.5318/- of the 2^nd complainant who was admitted at Warrier Dispensary, Thodupuzha on 11/11/2017 for Poly Arthritis, unspecified and discharged on 12/11/2017.  The said claim was settled by the 1^st opposite party’s TPA, who is the 2^nd opposite party  herein for Rs.4618/- on 05/02/2018 vide NEFT UTR No.KKBK180364279583.  The deduction made in the said claim for Rs.650 was towards the X-Ray and ECG of which reports were not given by the complainant to the opposite party.    Thereafter the complainant approached the 2^nd opposite party with a claim for Rs.35,000/- for the treatment expenses of the 2^nd complainant  who  was again admitted at the same dispensary on 22/11/2017 for the very same complaints and she was discharged on 05/12/2017.  The said claim was processed and settled for Rs.10,000/- on 15/03/2018 vide NEFT UTR No. KKBK 180741103483.  The deduction made in the said claim for Rs.25,000/- was based on excess of sub limit.

5 . As per policy condition 2.3, ‘Expenses incurred for Ayurveda and Homeopathy treatment are admissible up to 20% of the sum insured for any one illness’.  Here, the sum insured is Rs.50,000/- and the complainants are eligible only the 20% of the sum insured which is Rs.10,000/- and the same has been reimbursed by these opposite parties.  Therefore the complainants are not at all eligible or entitled for any amount in excess of the amount already received by the complainants from this respondent.  In these circumstances, it is also humbly submitted that there  was no deficiency of service on the part of the opposite parties in honouring the claims of the complainants.  All the averments contrary to these are false and hence denied.

 

(Cont......6)

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6 . Bystanders expenses are not covered under National Mediclaim Policy.  Hence the petitioners are not entitled to get any amount on account of bystander expenses.

7 . The cause of action stated in the complaint is absolutely false and hence denied.  Mediclaim of the complainant were not rejected by the opposite parties as averred in the complaint.  Opposite parties prayed for dismissal of complaint with costs.

Though complainants raised certain allegations against opposite parties, policy document, treatment details, claim form submitted and repudiation letter if any are not produced.  The contentions of opposite parties are that as per condition No.5.15 of the policy,  if the insured person has not notify the company within 12 months in writing that he does not accept the disclaimer and intends to recover his claim from the company, then the claim shall be deemed to have been abandoned and shall not thereafter  recoverable.  The complainants had not given such notice to 1^st opposite party.  Next contention is that there was no deficiency of service on the part of opposite parties.  They contended that against the claim for Rs.5318/- for the treatment done at Warrier Dispensary, Thodupuzha from 11/11/17 to 12/11/2017, they have settled the claim by paying Rs.4618/- on 05/02/18 through NEFT.  Similarly for the treatment done in the same dispensary from 22/11/17 to 05/12/17, claim for Rs.35,000/- was preferred by the complainants  and the same was processed and settled for Rs.10.000/- on 15/03/18.  The deduction of Rs.25,000/- from the above claim was based on excess of sub limit.  As per policy condition 2.3, expenses for Ayurveda and Homeopathy  treatment are admissible up to 20% of the sum insured for any one illness.  Rs.10,000/- was paid being 20% of the sum insured Rs.50,000/-.  Bystander expenses are not covered under the said policy.  Opposite parties have produced terms and conditions of the policy.  It is settled law that deficiency in service if any is to

(Cont......7)

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be proved by the complainants.  Here, on several posting dates complainants were not present or represented.  On 06/02/2023 complainant was represented and prayed for evidence.  Hence the case was posted to 22/03/2023.  On that day both parties were not present and not represented also.  Hence the evidence was closed and taken for orders.  The attitude of the complainants shows that they are not interested in pursuing the matter.  In the absence of any evidence  from the side of complainants, this complaint is disposed off on merits  as follows.

We have perused the complaint and written version and policy document produced by opposite parties.  On a perusal of the same, following points arise for consideration.

1 . Whether there was deficiency in service on the part of opposite parties?

2 . If so, for what reliefs complainant is entitled to?

3 . Order to be passed?

Point Nos.1 and 2 are considered together.

As per clause 2.3 of policy document, it is clear that up to 20% of sum insured is only available for any one treatment under Ayurveda  or  Homeo system of medicine.  With regard to validity of clause 5.15, we are not entering into any finding thereon at this point of time for the reason that complainant failed to establish his case.  As the complainant has utterly failed to substantiate his contention with the support of documents, we are of the considered view that deficiency in service cannot be attributed to  opposite parties.  As deficiency in service is not proved, we find that complainant is not entitled to any relief as prayed for.  So point Nos.1 and 2 are answered as above.

(Cont......8)

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Point No.3.

In the light of our findings on point Nos.1 and 2 we hold that no relief to be given to the complainant.  Point No.3 is answered accordingly.

In the result, complaint is dismissed however, without any order as to costs.

Complainant shall take back extra copies filed without delay.

Pronounced by this Commission on this the 30^th  day of March 2023.

                                                                                               Sd/-

                                                                            SRI.AMPADY K.S., MEMBER

                                                                                            Sd/-

                                                                  SRI.C.SURESHKUMAR, PRESIDENT

                                                                                            Sd/-                                                                

                                                                        SMT.ASAMOL P., MEMBER

 

 

APPENDIX

Nil

 

 

                                                                                           Forwarded by Order  

 

 

                                                                                     ASSISTANT REGISTRAR