BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,
ERNAKULAM.
Date of filing : 21/12/2011
Date of Order : 30/10/2012
Present :-
Shri. A. Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member.
C.C. No. 708/2011
Between
Bindu. C.P., | :: | Complainant |
Chandramangalam (H), Thrikkariyoor. P.O., Kothamangalam. |
| (By Adv. Tom Joseph, Court Road, Muvattupuzha) |
And
The Branch Manager, Oriental Insurance Co. Ltd., | :: | Opposite Party |
Elenjickal Mathew Memorial Plaza, Church View Junction, Kothamangalam – 686 091. |
| (By Adv. A.R. George, Anthikkatt House, P.O. Vennala, Cochin - 28) |
O R D E R
Paul Gomez, Member.
1. The facts behind the complaint are as under :-
The complainant underwent treatment for cervical spondilosis and back pain for eight days. She was holding medical insurance policy with the opposite party covering the said period. When the claim application was preferred claiming Rs. 5,873/-, it was rejected on the ground that she was not entitled for the amount, since the treatment was not in an ayurvedic medical college as specific in Clause No. 2 1 (v) of the terms and conditions of the policy. Hence this complaint claiming the said amount along with interest @ 12% p.a. from the date of claim till realisation.
2. In the version filed by the opposite party, the repudiation was justified on the ground that the complainant could not recover the claim amount, since her treatment was in a private hospital. Hence, it is urged to dismiss the complaint with costs to the opposite party.
3. No oral evidence to the complainant. Exts. A1 to A3 were marked on his side. No oral evidence to the opposite party too. Ext. B1 was marked on their side. The learned counsel appearing on both sides were heard.
4. The only short point for determination is as to whether the repudiation is justified in law and its consequences.
5. There is no disagreement between the parties with regard to facts. Hence, we need not elaborate on the factual situation. The only bone of contention between the parties is as to whether the insured had undergone treatment in private ayurvedic hospital or in an Ayurvedic Medical College. While the opposite party is of the view that the Ayurvedic procedure undergone by the complainant was in a private hospital, the complainant partly admits the contention, but pleads that the hospital where she had carried out her treatment was working in association with an Ayurvedic Medical College viz. Nangeli Ayurveda Medical College, Kothamangalam. To prove this point, she has produced Ext. A3 certificate issued by Dr. Vijayan Nangelil.
6. The opposite party relies on Ext. B1 policy schedule, more particularly clause 2.1 V (Note) in support of their stand. The said note reads as follows :-
“In case of Ayurvedic/Homeopathic/Unani treatment, hospitalisation expenses are admissible only when the treatment is taken as in-patient, in a Government Hospital/Medical College Hospital.”
The learned counsel Mr. Tom Joseph who appeared for the complainant pleads that since the provision is vague, it must be construed in favour of the complainant. As it is well known that consumer Fora have no power to interpret the provisions of the terms and conditions of contract, we are not inclined to embark upon such a venture. But surely, we can take a liberal view by accepting doctors version in this case stating that the hospital is virtually an annexure to the Nangeli Ayurveda Medical College. Once that stand is taken, we think the said exclusion clause will not come in the way of allowing this complaint. Accordingly, we do so and hold that the complainant is entitled for reimbursement.
7. Then comes the question of nature of relief. The relief sought is the actual expenses incurred in the hospital with interest @ 12% p.a.. Unfortunately, she has not produced any material to substantiate the quantum of claim. Any how, since the opposite party has no disagreement with the said figure, we think there is nothing wrong in allowing the claim.
8. Consequently, the complaint is allowed as follows :-
The opposite party is directed to pay Rs. 5,873/- along with interest @ 12% p.a. from the date of claim till realisation.
The parties will bear their respective costs.
The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.
Pronounced in the open Forum on this the 30th day of October 2012
Sd/- Paul Gomez, Member. Sd/- A. Rajesh, President.
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
A P P E N D I X
Complainant's Exhibits :-
Exhibit A1 | :: | Copy of the discharge summary |
“ A2 | :: | Copy of the letter dt. 04-11-2011 |
“ A3 | :: | Copy of the certificate dt. 15-11-2011 |
Opposite party's Exhibits :-
Exhibit B1 | :: | Individual mediclaim policy schedule |
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