O R D E R
By Sri. C.T. Sabu, President :
The case of the complaints is that they have taken a medi-claim policy from the opposite party. They had to undergo Angioplasty and treatment for Coronary Artery Deceases in Amala Hospital from 07/12/12 to 11/12/2012. A medi-claim was lodged with opposite party with relevant documents which was repudiated. Complainant had sent a sum of Rs.4,80,000/- in the policy No.P/181213/01/2012/009860 the liability of the insurance company is limited to One lakh rupees.
2) Aggrieved by the repudiation a lawyer notice was sent on 08/05/14 but of no avail. It is alleged by the complainants that repudiation is deficiency in service being a culpable offence. It is therefore prayed that the claim may be allowed directing the opposite party to pay Rs.1,00,000/- (Rupees One lakh only) with 12% interest from 08/01/2013 and Rs.25,000/- towards compensation with cost.
3) Admitted the case. Issued notice to opposite party. Opposite party appeared and filed version through counsel. In the version, opposite party seriously objects the claim due to non-submission of relevant documents other than the photocopies. Cashless facility was not given due to non-availability of ID particulars. Denial of cashless facility is not the end of everything. The complainants are having another option to claim for reimbursement by submitting the documents within the period allowed.
4) In this case no relevant documents are produced before the opposite party. The opposite party did not get any opportunities to decide the merits of the claim based on the available medical document. Hence there is no deficiency in service. The claim may be dismissed with costs.
5) Then the case posted for evidence. The points for consideration are the following.
a) Is there any deficiency in service or unfair trade practice from
the side of opposite party ?
b) If so, what are the reliefs and costs ?
6) Both parties filed proof affidavits, documents, argument notes and the matter was heard in detail. Complainants’ documents were marked as Ext. P1 to P3. Ext. P1 is the copy of Senior Citizens Red Carpet Insurance Policy – Schedule; Ext. P2 is the Lawyer Notice dtd.08/05/2014 and Ext. P3 is the Registered Reply notice issued by the opposite party dtd.11/06/2014. Opposite party’s documents were marked as Exts. R1 to R3. Ext. R1 is the Denial of Cashless Letter dtd.14/12/12; Ext. R2 is the copy of Senior Citizens Red Carpet Insurance Policy and Ext. R3 is the Authorisation Letter dtd. 29/11/2016.
7) Appreciation of Evidence :
On examination of documents proof affidavits, argument notes this Forum is very well convinced that the complainants have miserably failed to prove their case. Cashless facility was repudiated in the absence of relevant documents. It is a mode of settlement where it is to be proved that there is emergency situations like impecuniosity and such other unavoidable situation. In case of cashless facility is not extended the other mode of settlement has to be availed.
8) It seems that there were no such efforts for settling a similar relief. This Commission is inclined to find that there is no deficiency in service on the part of opposite parties.
9) Reliefs and costs :
Complaint is devoid of any merits hence dismissed without costs.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Commission this the 15th day of December 2020.
Sd/- Sd/- Sd/-
Sreeja S. Dr.K.Radhakrishnan Nair C. T. Sabu
Member Member President
Appendix
Complainant’s Exhibits :
Ext. P1 copy of Senior Citizens Red Carpet Insurance Policy – Schedule
Ext. P2 Lawyer Notice dtd.08/05/2014
Ext. P3 Registered Reply notice issued by the opposite party dtd.11/06/2014.
Opposite parties Exhibits :
Ext. R1 Denial of Cashless Letter dtd.14/12/12
Ext. R2 copy of Senior Citizens Red Carpet Insurance Policy
Ext. R3 Authorisation Letter dtd. 29/11/2016.
Id/-
President
