BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 18/10/2011

Date of Order : 24/08/2012

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 573/2011

Between

And

O R D E R

A. Rajesh, President.

1. The case of the complainant is as follows :

The complainant is a mason and a member of the Health Care Policy of the opposite parties. During the course of his employment, he sustained injury and had to undergo treatment at Sanjo Hospital, Perumbavoor from 13-01-2011 to 19-01-2011. On 31-01-2011, the complainant submitted the insurance claim application before the opposite parties. The opposite parties repudiated the claim of the complainant vide letter dated 13-06-2011 stating that the claim of the complainant was discontinued. The complainant is entitled to get the insurance amount of Rs. 13,600/- from the opposite parties with interest together with compensation.

2. The version of the opposite parties :

The opposite parties are providing mediclaim service with the tie-up of Oriental Insurance Company. On 24-09-2009, the complainant and his wife had joined Pheno Gold Membership Scheme of the opposite parties. As per the scheme, the complainant is to pay premium instalments continuously for a period of 20 months. If he fails to remit the premium the policy lapses. The policy of the complainant was discontinued with effect from 24-11-2010 much prior to the injury and the hospitalisation of the complainant. The opposite parties are not liable to pay any insurance benefit to the complainant for the treatment, he had undergone subsequent to the discontinuation of the policy.

3. No oral evidence was adduced by the parties. Exts. A1 to A6 and Exts. B1 and B2 were marked on the side of the complainant and the opposite parties respectively. Heard the complainant who appeared in person and the counsel for the opposite parties.

4. The only point that came up for consideration is whether the complainant is entitled to get the insurance claim together with compensation?

5. Ext. A1 certificate of membership goes to show that the complainant and his wife enrolled as members of Pheno Gold Member Scheme of the opposite parties from 24-09-2009 to 23-09-2018. During which time, he was to remit insurance premium of Rs. 1,700/- each per month for 20 months without default. During the currency of the scheme, the complainant underwent treatment at Sanjo Hospital, Perumbavoor from 13-01-2011 to 19-01-2011 in furtherance of an injury sustained by him due to an accident evident from Ext. A5 discharge summary. The opposite party repudiated the claim of the complainant vide Ext. A3 letter dated 13-06-2011 stating that the membership of the complainant was discontinued from 24-11-2010 to 21-01-2011 due to violation of Clause 3 of the terms and conditions of Ext. B1 policy. Since uncontroverted, we are only to sustain the contentions raised by the opposite parties. Held so.

Pronounced in open Forum on this the 24^th day of August 2012.

Sd/- A. Rajesh, President.

Sd/- Paul Gomez, Member.

Sd/- C.K. Lekhamma, Member.

Forwarded/By Order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

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