O R D E R
By Sri. C.T. Sabu, President :
Facts :
Complainants case is that they had taken a medi-claim policy with the opposite party as per the policy No.P/181213/01/2015/004421. Complainants are husband and wife. 1st Complainant was hospitalised from 23/02/2015 to 04/03/2015. As diagonised AIS (R) MCA INFARCT RICA STENOSIS CAS DONE ON 28/02/2015. Complainant alleges that he is entitled to get the entire hospitalisation expenses Rs.1,20,000/- (Rupees One lakh twenty thousand only) opposite party had allowed only Rs.78,000/- (Rupees Seventy eight thousand only). The act of opposite party amounts to deficiency in service. Complainants have thus suffered great loss and hardships besides mental agony. Aggrieved by the above act of the opposite party a lawyer notice was sent to opposite party on 14/07/2015 but of no avail. Therefore it is prayed before the Hon’ble Commission to allow the balance amount of Rs.42,000/- with 12% interest from the date of claim and Rs.10,000/- towards compensation and also litigation expenses allowing the complaint.
2) Admitted the case and ordered notice to opposite party. Opposite party appeared before the Commission and filed version through their counsel. As stated by the opposite party the sum insured under the policy is Rs.78,000/- which is arrived at calculating the basic sum insured Rs.60,000/- plus cumulative bonus of Rs.18,000/- (Rupees Eighteen thousand rupees). Opposite parties paid the full sum insured of Rs.78,000/- on 28/04/2015. Hence no further amount is payable by the opposite party. Since the eligible amount has been paid by the opposite party no deficiency in service is there on the part of opposite party. Therefore complaint may be dismissed with cost.
3) The points for consideration are
a) Whether there is any deficiency in service from the side of
opposite party ?
b) If yes, reliefs and costs ?
4) When the case was posted for evidence both parties submitted proof affidavits. Complainant produced eight documents and marked as Exts. P1 to P8. Ext. P1 is the Discharge Summary from Mother Hospital Pvt. Ltd. (Dept. of Neuro Science); Ext. P2 series is the copy of Discharge Summary; Ext. P3 is the copy of Lawyer’s Notice dtd. 14/07/2015; Ext. P4 is the Postal A/D card;
Ext. P5 is the copy of Proposal Form; Ext. P6 is the copy of Claim Form; Ext. P7 is the copy of Discharge Summary; Ext. P8 is the copy of Carotid Angioplasty Report. From the side of opposite party four documents are produced and marked as Exts. R1 to R4. Ext. R1 is the Star True Value Health Insurance Policy Schedule; Ext. R2 is the copy of Proposal form; Ext. R3 is the copy of Claim Form Part A; Ext. R4 is the copy of Discharge Summary. No oral evidence has been tendered on both sides.
5) Appreciation of Evidence :
We have examined proof affidavits documents, argument notes and point raised during its final hearing. Out of the eight documents produced by the complainant this Forum specifically observe that the non-production of policy bond by the complainant is a serious lapse on the part of complainant. In the instant case, the sole question to be decided primarily by this Forum in order to decide the issues framed by is the liability of the insurer under the policy. Complainant has a pious duty and onus to produce the policy before this Forum. Failure on the part of complainant to prove the liability as prayed in the complaint is really fatal and go against him. Whereas the opposite party produced a copy of the policy which is very clear and the contentions of the opposite party is just and valid.
6) The sum insured is the maximum liability of the Insurer. As provided in the policy Rs.60,000/- plus cumulative bonus Rs.18,000/- comes about Rs.78,000/- . The complainant has miserably failed to prove the claimed liability over and above Rs.78,000/-. Complaint is devoid of any merits and there is no deficiency in service on the part of opposite party. A detailed discussion is quite unwarranted since the liability of opposite party is crystal clear and there is no contra evidence submitted by the complainant.
Relief and cost :
Having found that there is no deficiency in service the complaint is dismissed. Rs.500/- (Rupees Five hundred only) is awarded to the opposite party towards cost. Compliance of cost payment shall be made with in thirty days from the receipt of this order.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Commission this the 30th day of June 2021.
Sd/- Sd/-
Sreeja S. C. T. Sabu
Member President
Appendix
Complainant’s Exhibits :
Ext. P1 Discharge Summary from Mother Hospital Pvt. Ltd.
Ext. P2 series is the copy of Discharge Summary
Ext. P3 copy of Lawyer’s Notice dtd. 14/07/2015
Ext. P4 Postal A/D card;
Ext. P5 copy of Proposal Form
Ext. P6 copy of Claim Form
Ext. P7 copy of Discharge Summary
Ext. P8 copy of Carotid Angioplasty Report
Opposite Party’s Exhibits :
Ext. R1 Star True Value Health Insurance Policy Schedule
Ext. R2 copy of Proposal form
Ext. R3 copy of Claim Form Part A
Ext. R4 copy of Discharge Summary
Id/-
President
