D.of.F:30/11/2011
D. of O: 23/4/2012
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.NO.320/2011
Dated this, the 23rd day of April 2012
PRESENT:
SRI.K.T.SIDHIQ : PRESIDENT
SMT.P.RAMADEVI : MEMBER
SMT.BEENA.K.G : MEMBER
Manojkumar Naik.K.G,
S/o Gokul Naik, Manmahal,
Kotekani Road,, Near New Bus stand, : Complainant
Kasaragod.
(Adv.Shrikanta Shetty.K, Kasaragod)
1. Regional Manager, Regional Office :
New India Assurance Co.Ltd.
Kandam Kulathil Towers, M.G.Road,Ernakulam. :
2. The Branch Manager, New India
Assurance Co.Ltd. Gokul Bldg,
M.G.Road, Kasaragod. : Opposite parties
3. TTK Healthcare Services Pvt.Ltd,
2.H.B.Complex, 100ft BTM Ring Road,:
BTM first stage, BTM Lay out, Bangalore:
ORDER
SRI.K.T.SIDHIQ : PRESIDENT
Case of the complainant in brief is as follows:
Complainant is insured with opposite parties as per Janatha mediclaim policy for the period from 11/2/2011 to 10/2/2012. As per the policy family members of the complainant are also covered for the benefits of the policy. The policy is a continuation of several years’ previous policies. 3rd opposite party is the Third Party Administrator of opposite parties 1&2. Wife of the complainant Reshma felt difficulty in breathing and consulted Dr.Gautham Kulamarva. He referred her to Mangala Hospital there she admitted from 23/8/11 to 25/8/11. From there it was diagnosed as polipodial Lesion on glottis obstructing the airway which is the cause for difficulty in breathing. Emergency Laser excision in glottis lesion with diagnostic bronchoscope under general anesthesia done on 23/8/11. The hospital bills for the treatment come around 56516.77/- the claim for cashless benefit is denied by 3rd opposite party without assigning any reason. Later complainant personally filed application for claim and sent on 2/9/11. But was no reply. Hence the complaint.
2. According to opposite parties the claim is settled as per the policy conditions subject to the term and limitations and a sum of 15719/- is paid to the complainant as per cheque dtd.16/11/2011 and the complainant is not entitled for the entire amount spent in view of the caps stipulated in the policy. The complaint is therefore deserves a dismissal.
3. Complainant filed proof affidavit in support of his case. Exts.A1 to A9 marked. On the side of Exts.B1 to B3 marked. Both sides heard.
4. Ext.A3 is the copy of the bill issued from Mangala Hospital shows that a sum of 57516.77 is spent for the treatment and medicines of Mrs. Reshma i.e., the wife of complainant.
4. But as per Ext.B3 schedule of payment for specified surgeons and other surgeons maximum charges inclusive of room /ICU / OT charges / surgeons/ Anesthetist. etc is limited to particular figures. Ext.B1 shows how the 3rd opposite party arrived at the sum paid to the complainant as per Ext.B3 schedule.
On a careful examination of Exts.B1&B3 and also Ext.A3 medical bill we could see that the opposite parties are paid the amount as per the terms and condition of the policy.
5. Insurance being a contract both the insurer and insured are bound by the terms of the said contract. The Janatha Mediclaim policy also contains certain terms conditions, limitation and stipulations. Both parties are bound by them.
6. On going through Ext.A3 medical bill and Ext.B3 it is seen that the opposite party has awarded the claim as per Ext.B3 schedule that is binding on complainant.
7. Therefore we do not find any deficiency in service on the part of opposite party. Hence the complaint fails and dismissed without any order as to costs.
Exts:
A1-copy of policy
A2-copy of discharge summary
A3- copy of hospital bills
A4- copy of lawyer notice
A5 to A7- AD cards
A8-copy of cheque
A9-copy of letter sent from OP.2 to OP.3
B1- Mediclaim Computation
B2- Copy of policy
MEMBER MEMBER PRESIDENT
eva
