IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Saturday the 30th day of July, 2016
Filed on 20.05.2015
Present
- Smt. Elizabeth George (President)
- Sri. Antony Xavier (Member)
- Smt.Jasmine.D. (Member)
in
C.C.No.155/2015
between
Complainant:- Opposite Parties:-
Sri. Syamlal Sasi 1. Sri. Ramnik Hiralal Parekh
Malayiltharayil House Director, United Healthcare
Puthiyavila P.O. Parekh TPA Private Ltd.
Kayamkulam – 690 531 3B/1, Gundecha Onclave
Alappuzha District Kherani Road, Sakinaka
Andheri (East), Mumbai
Maharashtra – 400 072
2. Sri. Gopalan Sreenivasan
Managing Director, New India
Assurance Company, Building 87
M.G. Road, Fort Mumbai
Maharashtra – 400 001
(By Adv. C. Muraleedharan – for
Opposite parties)
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
The complainant’s father was treated on severe knee pain at Amritha Institute of Medical Science where the illness was diagnosed and confirmed as Osteoarthritis on both knees. The further treatments were carried out at Krishnendhu Ayurveda Hospital where the treatment procedure continued for 14 days. The hospitalization expense claim submitted on 10th March, 2014. But the claim was rejected without any reasons. He had the policy coverage since 28th October 2010 till date. But he had no benefits out of the same. All his claims were rejected on invalid grounds, hence the complaint.
2. The version of the first opposite party is as follows:-
The Forum has no jurisdiction to entertain the complaint. The policy was issued from Chennai office of the New India Assurance Company. No cause of action on part of cause of action was arisen within the jurisdiction of this Forum. The claim of the complainant was that his father was admitted in the Ayurveda hospital for neck pain, low back pain bilateral knee pain and claim amount for Rs.29,415/- and post hospitalization expenses for Rs.5,409/-. But the X-ray and laboratory examination not consistent with or incidental to the diagnosis of positive existence of and treatment of any ailment, sickness and injury for which confinement is required at hospital or nursing home as per condition No.4.4.11 of policy. Thus the claim was repudiated and letter sent. All other allegations are absolutely false and devoid of any merit. Since the policy is a contract of indemnity the conditions and exclusions are equally applicable to both parties. Hence there is no deficiency in service on the part of the opposite party and the complain may be dismissed inliminae on that ground. The complainant not entitled to get any amount of compensation and interest from the opposite party.
3. Additional 2nd opposite party also filed version adopting the same contentions of the first opposite party.
4. The complainant was examined as PW1. The documents produced were marked as Exts.A1 to A20. Opposite parties filed proof affidavit and produced one document marked as Ext.B1.
5. The points that arose for consideration are as follows:-
1) Whether the complaint is maintainable?
2) Whether there is any deficiency in service on the side of the opposite parties?
3) If so the reliefs and costs?
6. Point No.1:- According to the opposite parties the Forum has no territorial jurisdiction to entertain the complaint, since the policy was issued from Chennai office New India Assurance Company Ltd. The complainant’s father was treated in the Amritha Hospital and thereafter at Krishnendhu Ayurveda Hospital at Karthikappally and the claim of the complainant was for the medical reimbursement of his father. Since the part of cause of action arisen within the jurisdiction of the Forum, the complaint is maintainable.
7. Point Nos.2 & 3:- According to the complainant, his father was treated for severe knee pain at Amritha Institute of Medical Science and following identification of the illness, the further treatments were carried out at Krishnendhu Ayurveda Hospital, Karthikappally. The complainant’s employer had provided him medical insurance for which a total coverage of 2.5 lakhs per year. His claim for the medical reimbursement was submitted on 10th March, 2014 and it was rejected without any reason. According to the opposite party they rejected the claim of the complainant, since the X-ray and laboratory examination not consistent with or incidental to the diagnosis of positive existence of and treatment of any ailment, sickness and injury for which confinement is required at hospital or nursing home. The opposite party produced the medi-claim policy copy which marked as Ext.B1. The period of insurance as per the policy is 1.11.2013 to 31.10.2014. The policy covers the family of the employee + 3 dependants included parts. In this case, the complainant’s father was treated in the Amritha hospital and afterwards his treatments were carried out at Krishnendhu Ayurveda Hospital. Ext.A1 produced by the complainant shows that he is entitled to get reimbursement claim for hospitalization in selected hospitals. Ext.A5 series are the email contacts by the complainant with the opposite party. Ext.A18(1) medical certificate issued by the Chief Physician, Krishnendhu Ayurveda Hospital which shows that the complainant’s father was admitted there on February 17trh 2014 and discharged on March 2nd 2014 and he was treated there on neck pain, low back pain and bilateral knee pain. Ext.A18(2) dated 13.2.2014 is the medical certificate dated 13.2.2014 issued by the Professor, Department of Orthopedic, Amritha Hospital, Kochi which show that the complainant’s father had bilateral knee pain and he is advised to have medication. The medical bills issued from the Amritha Institute of Medical Science also produced and marked as Ext.A7. Ext.A3 series (1) and (2) the detailed sheets of claim No.722743. The total amount claimed is Rs.5409 + 29415 = Rs.34824/-. The opposite party repudiated the claim as per the condition No.4/11 of the policy. The complainant also produced the X-ray report and ECG report and blood test report. Since all the documents produced as demanded by the opposite party, they cannot repudiate the claim on the technical grounds. The repudiation of the claim No.722743/1 amounts to deficiency in service on the part of the opposite parties.
In the result, complaint is allowed. The opposite parties are directed to pay Rs.34,824/- (Rupees thirty four thousand eight hundred and twenty four only) with 9% interest from the date of filing the complaint till realization to the complainant. The opposite parties are further directed to pay Rs.3,000/- (Rupees three thousand only) towards compensation and Rs.2,000/- (Rupees two thousand only) towards costs of this proceedings to the complainant. The order shall be complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant transcribed by her corrected by me an pronounced in open Forum on this the 30th day of July, 2016.
Sd/- Smt.Elizabeth George (President)
Sd/- Sri. Antony Xavier (Member)
Sd/- Smt. Jasmine. D. (Member)
Appendix:-
Evidence of the complainant:-
PW1 - Syamlal Sasi (Witness)
Ext.A1 - Insurance ID
Ext.A2 - Insurance details
Ext.A3 - Insurance claim history
Ext.A4 - Email communication details after claim submission
Ext.A5 - Email communication details through insurance Ombudsman
Ext.A6 - Claim form – Pre hospitalization (Claim No.722743/1)
Ext.A7 - Pre – hospitalization bills (including IP bill)
Ext.A8 - Discharge summary
Ext.A9 - Medical Certificate
Ext.A10 - Certificate of registration of the hospital
Ext.A11 - Indoor case sheet / ICP – Daily treatment record
Ext.A12 - Investigation report
Ext.A13 - Claim form – Post hospitalization (Claim No. 722743/2)
Ext.A14 - Post hospitalization bills
Ext.A15 - Rejection report for Claim No.722743/2
Ext.A16 - Certificate of diagnosis and discovery of illness
Ext.A17 - X-ray report
Ext.A18 - Doctor’s report on illness (Medical certificate)
Ext.A19 - ECG Report
Ext.A20 - Blood test report
Evidence of the opposite parties:-
Ext.B1 - Copy of the policy
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:- pr/-
Compared by:-
