By: Sri. Mohammed Musthafa Koothradan, Member
Case of the complainant is that the complainant is a reporter of Kerala Sabdam Magazine published from Kottayam. The Kerala Sabdam management had insured their staff to this opposite party for medical aid on 04/03/2010. As staff in the firm the complainant is a beneficiary in the scheme. As per the insurance scheme the complainant will get Rs. 30,000/- in the case of treatment with hospitalization. On 04/11/11/the complainant was admitted in the Korambayil Hospital at Manjeri in Malappuram district for the treatment of swelling on the legs and major tiredness. On the investigation of the doctor it is revealed that complainant has some problem in kidney and doctor give him medicines with an advice that if he do not get a better result with these medicines he must go for a better investigations. Then the complainant had registered this claim before opposite party with a claim No 008256882 for an amount Rs. 12,000/-. Opposite party repudiated the claim petition. Then complainant admitted in the MIMS Hospital Kozhikode and revealed that he is suffering Nephritic Syndrome and treated there, he was discharged with an advice for continue medicines and he spent an amount of Rs. 10.000/-. Again complaint registered claim with a claim number 85943 and he produced all medical bills and other documents to opposite party . This claim petition also repudiated by the opposite party . Hence complainant filed this complaint with prayer to give claim amount of Rs. 22,000/- and future treatment amount Rs.2373/- and Rs 25,000/- for mental agony with cost of Rs.5,000/-.
opposite parties filed version denying all allegations and averments except those are admitted here in the version. opposite parties admitting M/s Kerala sabdam, Kollam had taken Star True Value policy from Kollam office of the opposite parties, covering the limited medical insurance of its employees and their family members for a sum of Rs. 30,000/- each for a period of 04/03/2010 to 03/03/2011. The contract of insurance has been entered into Kerala Sabdam and Star Health and Allied Insurance Company. The policy covered the members of Kerala Union of working Journalist (KUWJ) and their family members. According to this policy the employees of Kerala sabdam who are the members of KUWJ and their family members are the beneficiaries of this policy. AS per the insurance conditions of this policy the insurance contract became operational in excess of the policy limited under the policy of KUWJ members. Though the contract of insurance is between M/S Kerala sabdam, Kollam and the opposite party . In this case Kerala sabdam has not made a party. So the case is bad for Non-jointer of necessary parties and hence to be dismissed.
The complainant was admitted on 04/01/2011 at Korambayil hospital, Manjeri in Malappuram district with complaint of generalized tiredness. On the same day opposite party received Pre-authorization request from the hospital in which the clinical findings shows h/o generalized tiredness. Since the treatment for Generalized tiredness falls out side the scope of policy as per exclusion close. Later the insured submitted complete claim form with discharge card, bills for Rs.8302 and lab reports. The complainant did not submit any case sheet copy as claimed by him. So allegations in paragraph 8 are not admitting by this opposite party . Based on the information on the medical records submitted by the complainant and the pre-authorization request submitted by the hospital the claim was repudiated. The medical report submitted by the complainant the diagnose was qualified by a question mark. Which meant that they were only provisional in nature? The final diagnosis was not made at that stage. Deciding liability under the insurance contract on uncertain grounds was not possible. So on 28/03/2011 the claim repudiation letter was sent to the complainant. More over the complainant was admitted for the treatment of his pre existing diseases, it is excluded in the policy. Again on 15/01/2011 the complainant was admitted at MIMS hospital Calicut for conducting renal biopsy and claimed insurance. opposite party received pre- authorization request letter from the hospital. Then the opposite party came to know that the complainant was admitted for a diagnostic procedure of renal biopsy. The cashless facility was denied on 18 01/2011 stating the reasons the admission was mainly for investigations and evaluations. Later the complainant submitted complete claim form with medical certificate including bills for Rs. 7092 and lab reports pertaining to the admission on 15/01/2011. It is repudiated with the above stated reasons. There is no deficiency of service in the side of opposite party . So the complaint may be dismissed with cost of this opposite party .
Both sides evidence adduced as affidavit and documents. Complainant produced ten documents which are marked as Ext A1 to A10. opposite party produced ten documents which are marked as Ext
B1 to B10. No oral evidence adduced both sides.
The following points are considered in this matter.
Point (a):- Whether the complaint bad for Non-jointer of necessary parties ?
Point (b):- Whether any deficiency of service in the side of opposite party ?
Point ©:- If so what is the relief and cost ?
Point (a):- Whether the complainant is bad for non- jointer of necessary policies?
Point (b):-Whether there is any deficiency of service in the side of opposite party ?
Point(c):- If so what is the relief and cost?
Point (a):- According to the version and affidavit of opposite party M/S Kerala Sabdam, Kollam is a necessary party in this matter and the complainant has no locus standing to file this complainant, because M/s Kerala Sabdam has used of their workers. The contractual obligation between M/s Kerala Sabdam Kollam and the opposite parties. But opposite party has issued separate policy certificate and it mentioned the name and address of complainant and his family complainant has produced the insurance certificate and it was marked as Ext. A1. In the light of Ext A1 his family members are beneficiaries of the insurance and they are eligible for getting the insurance, so he can claim the insurance so he can continue the insurance. So the complainant is a beneficiary in this policy, All the details mentioned in the Ext. A1 policy articles. The next question was whether the complainant was eligible for getting the amount claimed or have any ban to get his treatment amount from opposite party. First the complainant admitted in Korambayil Hospital Manjeri and treated there. The complainant was admitted for some days in the hospital. For proving the admission all documents had produced by the complainant. The 11nd time also the complainant was admitted for some days in the MIMS Hospital calicut. Both time the complainant was admitted and treated and, the investigation was in the part of treatment. By these investigation the doctor find out his decease and give medicines. So the opposite party have no right to say it is only a investigations because one of the reason for repudiate the claim
was the complainant admitted for investigation, not for treatment. The next conduction raised by the opposite party was the complainant is a member of KUWJ and he had received a compensation as member of KUWJ. Opposite party is liable to give the excess amount . The complainant produced A7 to A10 documents, it shows he had taken a membership in KUWJ on 9/03/11 alone, that mean on9/03/11 onwards he got the insurance benefit of KUWJ. The complainant was admitted before 9/3/11. So there is no chance for get the medical benefit of KUWJ scheme without a major reasons claim repudiation was not a good practice of opposite party. Opposite party had done deficiency of service and unfair trade practice against the complainant and opposite party must compensate the complaint.
Point (1):- Complainant had spent an amount of Rs. 22,000 for the treatment and Rs. 2373 for the future treatment. Opposite party must give these amount of Rs. 24373 with compensation of 5000 with cost of Rs. 2000.
In this result we allow the complainant and ordered opposite party to pay Rs. 24,373 as treatment expense with compensation of Rs. 5000 with cost of Rs.2000 to the complainant. The order must be realize within one month from receiving the order copy.
Dated this 6th day of February , 2013
sd/
E. AYISHAKUTTY, MEMBER, (In-Charge of President)
sd/-
MOHAMMED MUSTHAFA KOOTHRADAN, MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Ext.A1to A10
Ext.A1(s) : Star Health, Star True value health insurance policy schedule, dated,04/03/2010
Ext.A2 : Claim form for medical insurance from opposite party
Ext A3 : Claim form for medical insurance from opposite party dated, 15/01/2011
Ext A4 : Claim repudiation letter from second opposite party.
Ext A5 : Discharge summery of MIMS hospital Calicut.
Ext.A6 : Out patient Bill from MIMS Hospital Calicut
Ext.A7 : Cash received receipt of District Unit of K. U. W. J, amout Rs.750/- dated,19/03/11
Ext A8 : Cash received receipt of District Unit of K. U. W. J
Ext A9 : A letter from K.U.W.J. Dist. Committee, dated, 28-07-2012
Ext A10 : A letter issued from Press Club Malappuram, dated, 16-08-20101
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1 to B10
Ext.B1 : Claim form for medical insurance from opposite party.
Ext.B2 : Claim form for medical insurance from opposite party.
Ext.B3 : Test results from MIMS hospital Calicut , Department of laboratory medicine
Ext.B4 : Discharge bill from MIMS hospital Calicut
Ext.B5 : Histopatholgy report from MIMS hospital department of clinical laboratory
Ext.B6 : Scanning report from Manu scan centre, Manjeri
Ext.B7 : Discharge summery of Korambayil Hospital manjeri
Ext.B8 : Cash bill from Korambayil Hospital Manjeri
Ext.B9 : Hormons Assay of immuno assay from Korambayil hospital Manjeri
Ext.B10 :Electro Cardio Gram from Korambayil Hospital Manjeri
Sd/-
E. AYISHAKUTTY, MEMBER, (In-Charge of President)
sd/-
MOHAMMED MUSTHAFA KOOTHRADAN,MEMBER
