CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM Present Sri. Santhosh Kesavanath P. President Smt. Bindhu M. Thomas, Member K.N. Radhakrishnan, Member CC No. 126/2009 Friday, 29th day, of October , 2010 Petitioner : Joncy Abraham Kunnamthanam House, Kothala P.O. Kottayam. (By Adv. Anu George) Vs. Opposite party : Oriental Insurance Co. Ltd., Branch Office, Rajeswari Complex, 1st Floor, Perunna, Changanacherry. (By Adv. Agi Joseph) O R D E R Sri. K.N. Radhakrishnan, Member The case of the complainant filed on 30..4..2009, is as follows: He had taken a health insurance policy from the opposite party for a period from 30..3..2006 to 29..3..2007. On 12..2..2007 the complainant and his wife admitted us C.M.C Hospital, Velloore for the treatment of SINUSITIS. Both of them were discharged on 17..2..2007 after the treatment. He had spent an amount of Rs. 9581/- for his treatment, which includes, the total in patient discharge bill which amounted to Rs. 9,681/-, He had spend an additional amount of Rs. 10,000/- towards transportation expenses and by stander’s expenses. The medical bill of the complainant’s wife amounted to Rs. 10,264/-. Thereafter complainant submitted two sets of claim with the opposite parties on 23..2..2006. But on 6..6..2007 complainant received a letter repudiating his claim on the flimsy reason that both the complainant and his wife have undergone a complete medical check up which are not connected with the above disease. Actually the complainant and his wife had undergone only necessary medical treatments by which their illness was diagnosed as chronic Sinusitis . The repudiation of the claim was arbitrary and amounts to deficiency in service. The complainant was entitled the claim amount. Hence this complaint. The notice was served with the opposite party. They appeared and filed their version contending as follows: The case of the complaint is not maintainable either in law or on facts. The complainant and his wife are admitted at CMC Hospital for complete medical check up which is not related to any diseases and the same is not payable under the terms and conditions of the policy. They are not treated for any diseases as per the terms and conditions of the policy. The claim is totally false and no legal basis. Treatments and expenses for sinusitis are not covered under the policy. Expenses incurred for food by standers expenses and traveling expenses are not covered under the policy. The complainant and his wife are not covered under the alleged policy. There was no deficiency in service on the part of the opposite party. Hence the complaint may be dismissed with costs. The complainant filed proof affidavit and documents which are marked as exhibits A1 to A8. The opposite party filed proof affidavit and one document which is marked as exhibit B1. Heard both sides. We have gone through the complaint, version and documents of both sides. The case of the complainant is that the opposite party had repudiated the claim amount without any sufficient reasons. According to them they are eligible for the entire claim as per policy. The opposite party has taken a contention that the treatment expenses of the complainant was not come under the purview of the terms and conditions of the policy . According to the opposite party the ailment and the treatment of the complainant and his wife are not come under the terms and conditions of the policy. From the available documents and evidences it can be seen from Exibit A1 the policy of the complainant’s are continuing one and not a fresh policy. Moreover the opposite party has taken a contention that the ailment and treatment of the complainants are not come under the preview of the terms and conditions of the policy. From the policy it can be seen that the ailment and the treatment of the complainants are not excluded from the policy. The ailment and the treatment of the complainants are within the purview of the policy. The complainant is entitled for the claim amount as per the policy. So, we are of the opinion that the case of the complainant is to be allowed. In the result the complaint is allowed as follows: We direct the opposite party to pay the claim amount to the complainant as per policy and pay Rs. 2,500/- as compensation for inconveniences and pay Rs. 1000/- as costs of these proceedings. The order shall be complied with within a period of one month from the date of receipt of a copy of this order. The order not complied within one month the amount will carry interest @ 10% per annum from the date of the order till payment. Sri. K.N Radhakrishnan, Member Sd/- Sri. Santhosh Kesavanath P., President Sd/- Smt. Bindhu M. Thomas, Member Sd/- APPENDIX Documents produced by complainant: Ext. A1: Copy of policy schedule Ext. A2: In-patient discharge bill dt: 17..2..2007 Ext. A3: In-patient discharge bill dtd: 17..2..2007 Ext. A4: Copy of repudiation letter dt: 6..6..2007 Ext. A5: Copy of discharge summary Dt: 17..2..2007 Ext. A6: Copy of discharge summary Dt: 17..2..2007 Ext. A7: Copy of policy schedule Ext. A8: copy of receipt. Document produced by Opposite party Ext. B1: Copy of policy proposals. By Order, Senior Superintendent Received on / Despatched on amp/4cs
| | [HONORABLE Bindhu M Thomas] Member[HONORABLE Santhosh Kesava Nath P] PRESIDENT[HONORABLE K.N Radhakrishnan] Member | | 
