IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA.

Dated this the 29^th day of March, 2010.

Present:- Sri. Jacob Stephen (President)

Smt. C. Lathika Bhai (Member)

Sri. N. Premkumar (Member)

C.C. No. 166/2005

Between:

1. Varghese Daniel,

Vallikkattu Veedu,

Chengaroor P.O.,

Mallappally, Pathanamthitta.

2. Saramma Daniel, W/o Varghese-

Daniel, ---do---    ---do---

(By Adv. T.S. Radhakrishnan Nair)                                                           ....   Complainants.

And:

1. The Manager,

National Insurance Company Ltd.,

Divisional Office,

St. Joseph Building,

Opp. Cotton Hill School,

Vazhuthacaudu.,

Thiruvananthapuram – 14.

2. The Manager,

National Insurance Co. Ltd.,

Branch Office, P.B. No. 37,

Ennakkattil Estate, M.C. Road,

Thiruvalla – 689 101.

3. The Manager,

National Insurance Co. Ltd.,

Branch office, Kallunkalthara-

Building, Kozhencherry Road,

Pathanamthitta.

(By Adv. Sam Koshy)                                                                                ....   Opposite parties.

ORDER

Sri. Jacob Stephen (President):

                        The complainants have filed this complaint against the opposite parties for getting a relief from the Forum.

                        2. The facts of the complaint in brief is as follows:-  The first complainant is the husband of the second complainant.  The complainants took a Universal Health Insurance Policy vide policy No. 570202/48/04/8500364 dated 20.01.2005 from the opposite parties along with their children Deena Daniel and Dimple Daniel.  The said policy is valid from 23.01.2005 to 22.01.2006.  As per the terms of the policy, the policy holders are entitled to get Rs.30,000/- each for their treatment.  While so, the second complainant had undergone treatment at Muthoot Medical Centre, Kozhencherry as inpatient from 22.04.2005 to 02.05.2005 in connection with complications to her uterus.  For the said treatment, the second complainant had incurred an expense of Rs.32,177/-.  As per the terms and conditions of the policy, the second complainant is entitled to get Rs.30,000/- and the first complainant filed a claim form before the opposite parties.  But the first complainant received a letter-dated 16.08.2005 from TTK Health Care Service Pvt. Ltd, Ernakulam intimating that the complainants are entitled only Rs.9,750/- for the said treatment and given the said amount to the complainants.  The amount given to the complainants is against the policy conditions, which is a deficiency of service from the part of the opposite parties, which caused mental agony and financial loss to the complainants.  Hence this complaint for getting the claim amount of Rs.30,000/- less the amount already received along with compensation of Rs.10,000/- and the cost of this proceedings.

                        3. The opposite parties entered appearance and filed a common version with the following main contentions: The opposite parties admitted the policy in favour of the complainants and the treatment of the second complainant and the receipt of the claim form from the first complainant.  After processing the claim, an amount of Rs.9,750/- was calculated and paid to the complainants.  Being not satisfied with the above amounts, the complainant placed grievance with the opposite parties, which was referred to M/s. TTK Health Care Services Ltd., for clarification.  They, in turn, addressed directly to the complainant vide their letter-dated 16.08.2005 along with their medi-claim computation sheet.  The said computation was based on the terms laid down in clause 1.2A, 1.2B, and 1.2C of the terms and conditions attached with the policy, which dictate some limits as to the payment under the policy, which reads as follows:

                        1.2A – “Room/Boarding expenses as provided by the nursing 

                                   home/hospital upto 0.5% of the sum insured per day.  If admitted  

                                   in I.C. Unit 1% of sum insured per day.

                        1.2B – “Surgeon, Anaesthetist, Consultant, Specialist fee/nursing expenses 

                                   upto 15% of sum insured per illness/injury.

                        1.2C – “ Anaesthesia/Blood/Oxygoen/OT Charges/Surgical    

                                   applications/Medicines/Xry/Dialysis/Chemotherapy/    

                                   Radiotherapy /Cost of pace maker/artificial limb-altogether -15%

                                   of the sum insured.

                        4. The total expenses limited per injury/illness is limited to Rs.15,000/-.  It is evident from the complaint itself that the sum insured is Rs.30,000/-.  The above medi claim computation is made with strict adherence to clauses 1.2A,1.2B and 1.2C.  Hence there is no deficiency in service from their part.  With the above contentions, opposite parties pray for the dismissal of the complaint.

                           5. On the basis of the above pleadings, the only point to be decided whether this complaint can be allowed or not?

                          6. The evidence of the complainant consists of the oral deposition of PW1 based on the proof affidavit filed by the first complainant and Exts.A1 to A4.  Opposite parties’ evidence consists of the oral evidence of DW1 based on the proof affidavit of the second opposite party and Ext.B1.  After closure of evidence, both sides were heard.

                           7. The Point:  The complainant’s case is that he is a valid policy holder of Universal Health Insurance Policy of the opposite parties.  The complainant had incurred an amount of Rs.32,177/- for the medical treatment of the second complainant.  As per the terms of the policy, he is entitled to get Rs.30,000/- from the opposite parties and made a claim for the said amount.  But the opposite parties had paid only Rs.9,750/- instead of Rs.30,000/-.  The non-payment of the full insurance claim by the opposite parties is a deficiency of service and the opposite parties are liable to the complainant for the said deficiency.

                           8. In order to prove the complainants’ case, the first complainant filed a proof affidavit narrating his case.  On the basis of the proof affidavit, the first complainant was examined as PW1 and the documents produced by PW1 were marked as Exts.A1 to A4.  PW1 was cross-examined by the counsel for the opposite parties.  Ext.A1 is the photocopy of the policy certificate in the name of the complainants and their children.  Ext.A2 is the photocopy of the letter-dated 16.08.2005 issued by TTK Health Care Services Pvt. Ltd. to the first complainant with medi-claim computation statement intimating the first complainant that he is eligible to get only Rs.9,750/- in his claim.   Ext.A3 is the photocopy of the hospital bill for Rs.32,177/- issued by Muthoot Medical Centre, Kozhencherry in the name of the second complainant.  Ext.A4 is the terms and conditions of the medi-claim insurance policy in which the word medi-claim is struck out and in that place the words Universal Health is written. 

                            9. On the other hand, the contention of the opposite parties is that as per the terms and conditions of Universal Health Insurance Policy, the second complainant is entitled to get Rs.9,750/- vide clauses 1.2A, 1.2B and 1.2C.  As per the above clauses, certain limits are prescribed for the re-imbursement of medical expenses in Universal Health Insurance Policy.     After considering the prescribed limits, the eligible amount is calculated as Rs.9,750/- and the said amount was given to the complainant.  So, according to the opposite parties, they have not committed any deficiency of service.

                            10. In order to prove the contentions of the opposite parties, the second opposite party filed a proof affidavit and on the basis of the proof affidavit, the second opposite party was examined as DW1 and the document produced is marked as Ext.B1.  Ext.B1 is the terms and conditions of Universal Health Insurance Policy.

                            11. On the basis of the contentions of the parties, we have perused the entire materials on record and it is found that there is no dispute regarding the issuance of the policy, hospitalization of the second complainant and the treatment expenses of the complainant.  The dispute is with regard to the amount entitled to the complainants from the opposite parties for the medical expenses incurred by the complainants.  According to the complainants, they are entitled to get Rs.30,000/-.  But according to the opposite parties, as per the terms and conditions of the policy, the second complainant is entitled to get only Rs.9,750/-.  In this case, both the parties are relying on the policy conditions.  Both parties produced policy conditions.  The policy condition produced by the complainant is marked as Ext.A1 and the policy conditions produced by the opposite parties is marked as Ext.B1.  But Exts.A1 and B1 policy conditions are entirely different.  The title printed in Ext.A1 is “Medi-claim Insurance Policy (Revised)”.  But the printed word “Medi-claim” seen struck off and inserted words Universal Health in the place of Medi-claim.  But this correction is not an authenticated one.  So, we are not in a position to rely upon Ext.A1 and we are constrained to accept Ext.B1 policy conditions.  According to the opposite parties, they have calculated the amount entitled to the complainants on the basis of Ext.B1 policy conditions.  But on a comparative study, medi-claim computation sheet furnished by the opposite parties attached with Ext.A3, it is seen that the calculations are not corresponding to the clauses 1.2A, 1.2B and 1.2C of Ext.B1 policy conditions.  As per the terms and conditions of Ext.B1, the complainants are entitled to get 0.5% of the sum insured per day for room rent, 15% of the sum insured for the other expenses met by the complainant at the hospital in connection with the treatment such as medicines, surgery, O.T. charges, surgical appliances, Specialist expenses, nursing expenses etc.  But the calculations in the medi-claim computation sheet is not in accordance with the clauses 1.2A, 1.2B and 1.2C  So in our view, such a medi-claim computation sheet was prepared only for disallowing the complainant’s legitimate claim.  The opposite parties have no dispute regarding the Ext.A2 medical bill amounting to Rs.32,177/-.  So the opposite parties are liable to settle the complainants’ clim for the insured amount in accordance with the clauses 1.2A, 1.2B and 1.2C of Ext.B1.  Nature of expenses and the amounts noted in the computation sheet and Ext.A2 medical bill does not tally.  So the calculations in the computation sheet cannot be accepted.  So the contention of the opposite parties that they are liable to pay only the amount as per the computation sheet is not sustainable and the amount paid by the opposite parties cannot be treated as the eligible and entitled amount in this case.  To that extent, we find clear deficiency of service.  Hence this complaint can be allowed partly with compensation and cost.

                        12. In the result, this complaint is allowed partly, thereby the opposite parties are directed to calculate and pay the actual amount entitled to the complainant, less the amount already paid, on the basis of clause 1.2A, 1.2B and 1.2C of Ext.B1 policy conditions in respect of Ext.A2 hospital bill within 30 days from the date of receipt of this order with 9% interest per annum for the said amount from the date of filing of this complaint along with Rs.2,500/- (Rupees Two thousand five hundred only) as compensation and Rs.1,000/- (Rupees One thousand only) as cost to the complainant, failing which the complainant is entitled to realise an amount of Rs.7,500/- (Rupees Seven thousand five hundred only) as the balance amount of the claim with 9% interest per annum from the date of filing of this complaint till this day along with compensation of Rs.2,500/- (Rupees Two thousand five hundred only) and Rs.1,000/- (Rupees One thousand only) as cost and thereafter at the rate of 10% interest per annum from today till the whole realisation.

                        Declared in the Open Forum on this the 29^th day of March, 2010.

                                                                                                                                    (Sd/-)

                                                                                                                        Jacob Stephen,

                                                                                                                          (President)

Smt. C. Lathika Bhai (Member)                  :           (Sd/-)

Sri. N. Premkumar (Member)                    :           (Sd/-)

Appendix:

Witness examined on the side of the complainants:

PW1    :           M.V. Daniel.

Exhibits marked on the side of the complainants:

A1       :           Photocopy of the policy certificate isisued by the opposite parties to the

                        complainant.

A2       :           Photocopy of the letter-dated 16.08.2005 issued by TTK Health Care

                        Services Pvt. Ltd. to the first complainant.

A3       :           photocopy of the hospital bill for Rs.32,177/- issued by Muthoot Medical

                        Centre, Kozhencherry in the name of the second complainant.  

A4       :           Terms and conditions of the medi-claim insurance policy.

Witness examined on the side of the opposite parties:

DW1   :           Jacob Varghese.

Exhibits marked on the side of the opposite parties:

B1        :           Terms and conditions of Universal Health Insurance Policy.

                                                                                                                        (By Order)

                                                                                                              Senior Superintendent.

Copy to:- (1) Varghese Daniel, Vallikkattu Veedu, Chengaroor P.O.,

            Mallappally, Pathanamthitta.

(2)   The Manager, National Insurance Company Ltd., Divisional Office,

            St. Joseph Building, Opp. Cotton Hill School, Vazhuthacaudu.,

            Thiruvananthapuram – 14.

(3)   The Manager, National Insurance Co. Ltd., Branch Office, P.B. No. 37,

            Ennakkattil Estate, M.C. Road, Thiruvalla – 689 101.

(4)   The Manager, National Insurance Co. Ltd., Branch office,

Kallunkalthara Building, Kozhencherry Road, Pathanamthitta.

                  (5)  The Stock File.