BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI

Dated this the 25th day of March, 2009

Present:

SRI.LAIJU RAMAKRISHNAN PRESIDENT

SMT.SHEELA JACOB MEMBER

SMT.BINDU SOMAN MEMBER

C.C No.107/2008

Between

Complainant : Thomas Varghese, S/o Varghese,

Puthanparambil House,

Santhigiri Kara,

Chakkupalam Village,

Udumbanchola Taluk,

Idukki District.

(By Adv: T.S.Saji Thayyil)

And

Opposite Parties : 1. The Branch Manager,

Oriental Insurance Company Limited, Kanjirappally.

2. The Branch Manager,

Oriental Insurance company Limited,

Jyothi Super Bazar,

Thodupuzha - 685 584.

(Both by Adv: K.Pradeepkumar)

O R D E R

SRI.LAIJU RAMAKRISHNAN(PRESIDENT)

The complainant joined in a medi-claim insurance policy of the opposite party as No.438/07 for the period from 24.01.2007 to 23.01.2008 and paid a premium of Rs.538/- for the same. As per the schedule given by the opposite party, the policy coverage includes he himself, his wife Rosamma Thomas, and children Nebinmon Thomas and Nijithamol Thomas. The authorized agent of the company assured that all the treatment expenses of the above persons were covered in the policy. The complainant's wife was admitted in the Santhigiri Ayurveda and Sidha Hospital, Kallar in Idukki District for the treatment of her back bone disease from 17.06.2007 to 2.07.2007. The treatment expenses incurred Rs.17351.95. The complainant approached the opposite party for the insurance amount of his wife with discharge card and all the other details, but the opposite party repudiated the claim and so the petition is filed for deficiency in service of the opposite parties.

2. The opposite party filed written version stating that they are not aware of the disease and treatment of the wife of the complainant. The complainant did not file any claim form to the opposite party for the treatment of his wife. If the petitioner files claim   form with supporting documents, the opposite party is ready to consider the same as per the conditions and contract of the insurance policy. The opposite party denied that the policy was taken by the complainant believing the words of the opposite party's agent that for treatment to all diseases, company will pay the treatment expenses. There is no deficiency in service on the part of the opposite parties.

3. The point for consideration is whether there was any deficiency in service on the part of the opposite parties, and if so, for what relief the complainant is entitled to ?

4. The evidence consists of the oral testimony of PWs 1 and 2 and Exts.P1 to P8 marked on the side of the complainant. No oral evidence adduced from the part of the opposite parties and Ext.R1 marked.

5. The POINT :- Complainant joined in a medi-claim insurance policy for his family with the opposite party. But they repudiated the claim when a claim was given for his wife's treatment. Complainant was examined as PW1. PW1 availed the policy for the period from 24.01.2007 to 23.01.2008. The health insurance policy was marked as Ext.P1. The premium for the same Rs.538/- was paid. As per the policy, the family member of the complainant, wife Rosamma, son Nebinmon, daughter Nijithamol were also having the coverage for diseases and hospitalization. The wife of PW1 was admitted in Santhigiri Ayurveda and Sidha Hospital, Kallar for treatment for her back bone. The expenses for the treatment was Rs.17351.95. Ext.P2 series is the copy of the bill for the same. Ext.P5 is the discharge card issued from the hospital. Ext.P6 is the medifitness certificate issued from the hospital. PW2 is the agent who insured the complainant and his family. PW2 deposed that he has sent all the details and documents to the company,

needed for the insurance claim of the complainant's wife. The counsel for the opposite party cross examined PW1 and PW2 and also filed written version. As per the opposite party, the treatment was not done in a Government hospital. The complainant is not liable to get the claim because the treatment was in a private Ayurveda hospital. No claim was also submitted by the complainant for his wife. Ext.R1 is the policy with conditions. The policy is admitted by the complainant. But the dispute is that the wife of the complainant was treated in a private hospital. As per Ext.R1, policy conditions produced by the opposite party, in the Section 2.1, where the definition of the hospital is defined as “Hospital/ Nursing Home means any institution in India established for indoor care and treatment of disease and injuries and which either

(a) Has been registered either as a Hospital/or Nursing home with the local authorities

and is under the supervision of a registered and qualified Medical Practitioner

OR

(b) Hospital/Nursing Home run by Government

OR

(c) Should comply with minimum criteria as under :

 i. It should have atleast 15 inpatient beds. In class "C" town having population of less than five lakhs the number of beds be reduced to 10.

ii. Fully equipped Operation Theatre of its own wherever surgical operations are carried out.

iii. Fully qualified nursing staff under its employment round the clock.

iv. Fully qualified doctor(s) should be in charge round the clock.

Ext.P6 is a treatment certificate issued from a registered medical practitioner with Reg.No.4189. Hence it is a gross deficiency in the part of the opposite party to repudiate the claim by this reason. So we think, it is proper to award Ext.P2(series) bill amount to the complainant ie, Rs.17351.95.

Hence the petition allowed. The opposite party is directed to pay Rs.17351.95 as per Ext.P2(series) bill to the complainant from the date of this petition and Rs.2,000/- as cost of this petition to the complainant within one month of receipt of a copy of this order, failing which the amount shall carry 12% interest per annum from the date of default.

Pronounced in the Open Forum on this the 25th day of March, 2009

SRI.LAIJU RAMAKRISHNAN(PRESIDENT)

SMT.SHEELA JACOB(MEMBER)

SMT.BINDU SOMAN(MEMBER)

APPENDIX

Depositions :

On the side of Complainant :

PW1 - Thomas Varghese

PW2 - K.M.Joseph

On the side of Opposite Parties :

Nil

Exhibits:

On the side of Complainant:

Ext.P1 - Universal Health Insurance Policy(Original)

Ext.P2(series) - Medical Bills(4 Nos) for total Rs.17351.95

Ext.P3 - Postal Receipt

Ext.P4 - AD Card

Ext.P5 - Discharge Summary

Ext.P6 - Medical Fitness Certificate dated 2.07.2007 issued by

Santhigiri Ayurveda & Siddha Hospital, Kallar

Ext.P7 - Universal Health Insurance Claim Form

Ext.P8 - Claim Form Certificate submitted by Dr.C.N.Sukumaran, DAM

On the side of Opposite Parties :

Ext.R1 - Policy Copy