THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Present:
Sri. Santhosh Kesavanath P., President
Smt. Bindhu M. Thomas, Member
CC No. 182/2009
Thursday, the 30th day of December, 2010.
Petitioner : Mathachan,
Panthirunazhiyil House,
South Gate P.O
Vaikom.
(By Adv. Avaneesh V.N)
Vs.
Opposite parties : 1) The Regional Manager,
New India Assuarance Co. Ltd.
Kandamkulathy Towers,
M.G Road, Ernakulam
2) Medi Assist India Pvt. Ltd.
Rep. by its Manager,
406, Chandralayam
Lurusupally Road,
Temple Lane, Ravipuram,
Cochin – 682 015.
O R D E R
Sri. Santhosh Kesavanath P. President.
Case of the petitioner is filed on 22..6.2009, is as follows:
Petitioner is a holder of Medi Claim Policy of the first opposite party. Second opposite party is the service provider appointed by the 1st opposite party. On 22..2..2008 petitioner met with an accident, while he was driving a motor cycle. Petitioner was taken to Carithas Hospital, Thellakom and admitted there as inpatient. Physician of the hospital noted Degeneration, disc disease noted at multiple level and the signal alterations involving inter muscular plane on right side along course of right brachial plexus and inter muscular hematoma. Petitioner was discharged on 28..2..2008 from Carithas hospital. Subsequent to the discharge from Carithas hospital petitioner was admitted at Santhigiri ayurveda & Sidha Hospital, Uzhavoor. Due to the accident petitioner incurred an expenses of Rs. 87,000/-. Since the expense was incurred during the policy period petitioner preferred a claim to the opposite party for reimbursement of Rs. 87,000/-. On 24..9.2008 petitioner received a letter from the opposite party repudiating the claim of the petitioner on the ground that petitioner was
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under the influence of alcohol at the time of accident. On 19..12..20089 petitioner made a representation to the first opposite party for getting the claim amount that to was rejected. According to the petitioner act of the opposite party in repudiating the claim of the petitioner amounts to deficiency in service. So, he prays for a direction to the opposite party to pay an amount of Rs. 87,000/- along with Rs. 15,000/- as compensation and cost of the proceedings.
Opposite party entered appearance and filed version contenting that the petition is not maintainable. Opposite party admitted the policy in the name of M/s. Kumarakom Water Transport in the account of the petitioner. Policy is valid from 8..12..2007 to 7..12..2008. The said policy is issued subject to the terms and conditions. According to the opposite party claim of the petitioner is repudiated on valid and reasonable ground. From the medical records it was seen that petitioner was under influence of alcohol at the time of admission in the Carithas hospital . Therefore as per exclusion close No. 4.4.6 of said policy petitioner is not entitled for any amount. Opposite party contented that there is no deficiency in service on their part. They pray for dismissal of the petition with their costs.
Points for determinations are:
i) Whether there is deficiency in service on the part of the opposite party?
ii) Relief and costs?
Evidence in this case consists of affidavit filed by both parties and Ext. A1 to A12 documents on the side of the petitioner and Ext. B1 to B3 documents on the side of the opposite party.
Point No. 1
Opposite party produced letter Dtd: 19..12..2008 said document is marked as Ext. B3. In Ext. B3 opposite party stated that on a scrutiny of the records received from the hospital, were the patient is under gone treatment, it was recorded that there was smell of alcohol on the petitioner. So as per clause 4.4.6 of the policy condition company is not liable for the treatment relating to use of intoxicating drugs and alcohol. The policy along with the conditions of the policy produced is marked as Ext. B1. In Ext. B1 as close 4.4 permanent exclusion is stated. In clause 4.4 it is stated that medical expenses incurred for or arising out of as stated in the sub clause 4.4 is excluded. In clause 4.4.6 it is stated that use of intoxicating drugs or alcohol is excluded. In our view by reading together clause 4.4. and clause 4.4.6 if the medical
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expenses is incurred for or arising out or use of intoxicating drugs, alcohol is excluded. Counsel for the opposite party vehemently argued that from A11 discharge summary produced by the petitioner it can be seen that at the time of admission the petitioner is having a smell of alcohol. So, the claim will come under the exclusion clause 4.4.6. In our view by reading together 4.4. and 4.4.6. It can be seen that exclusion is for the medical expenses incurred for or arising out of use of alcohol. Here from the available records it can be seen that there is a smell of alcohol or else at the most time of accident the petitioner consumed alcohol. But the opposite party has not adduced any evidence to prove that the accident was arised as a result of use of alcohol or else the opposite party failed to prove that the petitioner was under the influence of alcohol at the time of accident. The claim of the petitioner for an amount of Rs. 87,000/- is not disputed by the opposite party. In our view act of the opposite party amounts to deficiency in service. So, point No. 1 is found accordingly.
Point No. 2
In view of the finding in point No. 1., petition is allowed. In the result opposite party is ordered to pay the petitioner the claim amount of Rs. 87,000/-. Considering the facts and circumstances of the case no cost and compensation is ordered. The order shall be complied with within one month of receipt of a copy of this order. If the order is not complied as directed petitioner is entitled for interest at the rate of 9% from the date of repudiation till realization
Dictated by me, transcribed by the Confidential Assistant, corrected by me and pronounced in the Open Forum on this 30th day of December, 2010.
Sri. Santhosh Kesavanath P., President Sd/-
Smt. Bindhu M. Thomas, Member Sd/-
APPENDIX
Documents for the Petitioner
Ext. A1: Copy of the Medi Claim Policy
Ext. A2: Letter Dtd: 24..9..2008 issued by the second opposite party to the
petitioner.
Ext. A3: Copy of the letter Dtd: 21..11..2008 from the second opposite party to
first opposite party
Ext. A4: Letter issued by the 1st opposite party to the petitioner Dtd: 19..12..2008
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Ext. A5: Copy of letter issued by the 1st opposite party to the petitioner dtdL 17..3..2009
Ext. A6series Medical bills
Ext. A7 Letter Dtd: 13..8..2009 issued by the first opposite party to the petitioner.
Ext. A8: Copy of discharge summary from Santigiri Ayurveda hospital
Ext. A9: Copy of the letter Dtd: 14..4..2008 issued by the Santigiri Ayurveda Hospital
Ext. A10: Copy of the discharge summary from the Lissy Hospital Dtd: 20..6..2008
Ext. A11: Copy of the discharge summary from Carithas Hospital
Ext. A12: Copy of certificate issued from Carithas hospital Dtd: 22..7..2008
Documents for the opposite party
Ext. B1: Copy of policy with condition
Ext. B2: Fax message from the Carithas Hospital to the first opposite party
Ext. B3: Letter Dtd: 19..12..2008 issued by the first opposite party to the petitioner.
.
By Order,
Senior Superintendent
Despatched on / Received on
amp/5 cs.
