Date of filing : 06-05-2008<br /> Date of Order: 27-11-2008.<br /> IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD<br /> CC.63/08<br /> Dated this, the 27th day of November 2008.<br /> PRESENT<br /> SRI.K.T.SIDHIQ : PRESIDENT<br /> SMT.P.RAMADEVI : MEMBER<br /> SMT.P.P.SHYMALADEVI : MEMBER<br /> <br /> N.P.Ramachandran,<br /> S/o.T.A.V.Kunhambu,<br /> Residing Near Railway Station,<br /> Cheruvathur Village of Hosdurg Taluk, } Complainant<br /> Kasaragod District.<br /> (Adv. T.M. Jose,Hosdurg)<br /> 1. T.K.Muhammadali,<br /> Proprietor cum Owner,<br /> K.A.H. Memorial Hospital, } Opposite parties<br /> Cheruvathur Village of Hosdurg Taluk,<br /> Kasaragod District..<br /> 2. United India Insurance Company Ltd,<br /> Branch Office, Payyanur,Po,<br /> Kannur.District.<br /> (Adv.C.Damodaran) <br /> O R D E R<br /> SRI.K.T.SIDHIQ, PRESIDENT<br /> Complaint is against the non settlement of medi claim of complainant. According to complainant N.P.Ramachandran he is a policy holder of Universal Health Insurance Scheme of opposite party No.2. He along with his family joined in the scheme through opposite party No.1 namely K.A.H.M. Hospital, Cheruvathur. The complainant met with an accident on 31-05-2006 during the subsistence of policy. He was hospitalised in first opposite party’s hospital. After 3 days complainant was referred to Colaco Hospital, Managalore and treated there from 3-6-06 to 7-6-06. Thereafter again the complainant re-admitted in the first Opposite party hospital from 7-6-06 to 14-6-06. Subsequently he submitted the claim with medical records and bills for the insurance benefits to the first opposite party to submit it to second opposite party. But the claim is not settled by opposite party No.2 stating that there are some falsification in the medical documents. On enquiry 2nd opposite party told to the complainant that the treatment administered to the complainant at Colaco Hospital, Managalore from 3-6-06 to 7-6-06 also included in the period of hospitalisation of Opposite party No.1, KAHM Hospital. In the discharge summary issued from KAHM Hospital also the period of treatment shown as 1-6-06 to 14-6-06. Since false documents are created for claiming insurance benefits the claim is not allowed. Hence the complainant caused a lawyer notice to 2nd opposite party claiming insurance benefits but neither the payment was made nor received any reply. Hence the complaint alleging deficiency in service on the part of opposite parties claiming Rs.30,000/- from opposite parties the amount the complainant incurred towards his treatment.<br /> 2. Notice to both parties sent by registered post. Even though notices were served to both parties, Opposite party No.1 did not care to appear before the Forum. Hence opposite party No.1 was set exparte. Opposite party No.2 appeared and filed version.<br /> 3. According to Opposite party No.2 the complaint is barred by limitation since as per condition 5.11 of the policy issued to complainant the claim should have been filed within 12 months of repudiation of claim. On merits Opposite party No.2 contends that the bill submitted creates suspicion as the bills issued from Ist opposite party hospital contained medical bills pertaining to the dates on which the complainant was hospitalised in Colaco Hospital, Mangalore. Rs.40,000/- alleged to have spent by the complainant towards his treatment is false. Medical bills for Rs.14,000/- only are produced by the complainant for the settlement of claim. The complainant did not approach with clean hands for the settlement of claim. Therefore the non-settlement of the claim is quite legal and as per policy conditions. <br /> 4. Complainant filed affidavit in lieu of oral evidence. Exts A1 to A8 marked. The Divisional Manager of Division Office, Kannur filed counter affidavit. Exts B1 to B3 marked. Both sides heard and the documents perused.<br /> 5. According to Opposite party No.2 the bills for treatment submitted by complainant would fetch Rs.13,563/-. In addition to that complainant produced 5(a) to 5(h) series medical bills remaining with him after submission of all bills to opposite party No.1. Those bills amount to Rs.1626.17. So the total bills would fetch Rs.13,563/- + 1626.17 = 15189.17.<br /> 6. The contention of opposite party No.2 that the claim is barred by limitation in view of Condition 5.11 of the policy is not sustainable. The discharge of the complainant from opposite party’s Hospital was on 14-6-06 and the lawyer notice claiming insurance benefits to opposite party No.2 is seen issued on 5-4-07 clause 5.11 provides that the insured shall within 12 calendar months from the date or receipt of notice of repudiation shall notify the TPA/Company in writing that he does not accept such disclaimer and intends to recover his claim from the TPA/Company. In this case no such disclaimer/repudiation notice is seen issued to complainant. Moreover the complainant had preferred to notify the non-acceptance of disclaimer of the company by way of a lawyer notice dt.5-4-07 i.e. well within a period of limitation. Hence the contentions that the claim is barred by limitation not sustainable.<br /> 7. Opposite party No.2 has no case that the complainant has not treated in the hospital of Opposite party No.1 from 1-6-06 to 3-6-06 and from 7-6-06 to 14-6-06 so definitely opposite party No.2 is liable to settle at least the bills relating to that dates as per the universal health insurance policy issued to the complainant through opposite party No.1. The said bills would fetch Rs.10,641.08. Opposite party No.2 could not escape from the payment of said bills to complainant.<br /> 8. Opposite party No.1 who dealt with the claim of complainant has acted irresponsibly and negligently and there by caused mental agony and sufferings to the complainant. Opposite party No.1 is liable to compensate the complainant for the said sufferings.<br /> 9. Therefore we pass the following order.<br /> Opposite party No.2 shall pay a sum of Rs.10641.01 (Rounded to 10600/-) to the complainant. Opposite party No.1 is directed to pay a sum of Rs.3000/- towards the mental agony and sufferings caused to the complainant along with a cost of Rs.2000/-. Time for compliance one month from the date of receipt of copy of order.<br /> Sd/- Sd/- Sd/-<br /> MEMBER MEMBER PRESIDENT<br /> Exts.<br /> A1.Notice published by OP No.1.<br /> A2.Insurance Health card issued by OP NO.1<br /> A3.Dishcarge Card issued by OP No.1.<br /> A4.Discharge Summary issued by Colaco Hospital, Mangalore.<br /> A5 (a) to (h) series Bills.<br /> A6.. Dt.5-4-07 copy of lawyer notice.<br /> A7& A8 Postal acknowledgement cards.<br /> B1. Claim form<br /> B2. Cash Memo for Rs.13563/-<br /> B3. Certified copy of the policy.<br /> <br /> Sd/- Sd/- Sd/-<br /> MEMBER MEMBER PRESIDENT<br /> Pj/ Forwarded by Order<br /> <br /> SENIOR SUPERINTENDENT<br />