KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACADU THIRUVANANTHAPURAM APPEAL NO.1080/04 JUDGMENT DATED.10.1.2008 PRESENT SRI.M.V.VISWANATHAN -- JUDICIAL MEMBER SRI.S.CHANDRAMOHAN NAIR -- MEMBER Pappachan, Madathil House, Marangattukonam, -- APPELLANT Kalakam. (By Adv.S.Reghukumar) Vs. The Branch Manager, NewIndia Assurance Company Ltd., Divisional Office, P.B.No.213, -- RESPONDENT 2nd Floor, KSFE.Building, Chinnakkada, Kollam – 691 001. (By Ad.Sreevaraham G.Satheesh) JUDGMENT SRI.M.V.VISWANATHAN,JUDICIAL MEMBER The above appeal is preferred from the order dated.1st December 2004 of the CDRF, Kollam in OP.No.76/02 which was filed by the appellant herein as complainant against the respondent as opposite party claiming Insurance Medi claim under the Pravasi Sureksha Kudumbarogya Scheme. The aforesaid Insurance medi claim was repudiated by the opposite party on the groundthat the complainant/insured was having pre-existing disease and so the claim is excluded by the policy of Insurance issued under Pravasi Sureksha Kudumbarogya scheme. The Lower forum accepted the case of the complainant regarding deficiency of service on the part of the opposite party Insurance Company. But the claim of Rs.41615.68 was dis-allowed by the Lower forum on the ground that the opposite party insured failed to prove the medical expenses incurred by him. Lower forum awarded a sum of Rs.5000/- as compensation to the complainant on the ground of deficiency of service on the part of the opposite party. The complainant is not satisfied with the aforesaid order passed by the lower forum. Hence the present appeal. 2. We heard the counsel for the appellant/complainant and respondent/opposite party. The learned counsel for the appellant argued the case on the basis of the grounds urged in the memorandum of the present appeal. It is also submitted that the Insurance claim was proved by the oral testimony of the complainant as PW1 and Ext.P1 to P5 documentary evidence adduced from the side of the complainant. Thus, the appellant/complainant requested to modify the impugned order passed by the Lower forum and thereby to allow the entire claim for Rs.41615.68/-. On the other hand, the learned counsel for the respondent/opposite party (Insurance company) took the stand that the claim itself is un-sustainable as the insured was having pre-existing illness and thereby the claim was outside the scope of the policy of Insurance covered by P1 Insurance policy. Thus, the respondent Insurance Company requested for dismissal of the present appeal. 3. The points that arise for consideration are:- 1. Whether the appellant/complainant as insured has substantiated his claim for Rs.41615.68/- by adducing acceptable and cogent evidence? 2. Is there any legally sustainable ground to modify the impugned order passed by the lower forum in OP. No.76/02? 4. POINTS 1 & 2:- There is no dispute that the appellant/complainant was covered by P1 policy of Insurance issued by the respondent/opposite party Insurance Company. The case of the complainant is that he spent a sum of Rs.31615.68 towards the cost of medicine, surgical appliances, operation theatre charge, Nursing expenses, room rent etc. and further sum of Rs.5000/- was incurred towards boarding expense in connection with his inpatient treatment in the various hospitals namely; Mercy Hospital, Valakom, Kottarakkara, G.G.Hospital, Trivandum and Cosmopolitan Hospital, Trivandrum. The complainant has also claimed another sum of Rs.5000/- by way of compensation for the mental agony, sufferings and other damages. Thus, the total of Rs.41615.68 has been claimed in connection with his treatment in the aforesaid hospitals. 5. Ext.P1 to P5 are the documents produced from the side of the complainant (appellant) before the lower forum. Ext.P1 is the policy issued by the opposite party (respondent) Insurance Company under the Pravasy Suraksha Kudumba Arogya Scheme. There is no dispute that there was a subsisting medical Insurance during the relevant period and there is also no dispute regarding those aspects. P2 is only the receipt issued by the Insurance Company evidencing acceptance of the Insurance premium. P3 is the relevant document which deserves active consideration in the present case. The aforesaid P3 is only photostate copy of the discharge summary with case History and the progress notes & Doctors orders with respect to Mercy Hospital, Valakom issued in the name of the complainant who was admitted as an inpatient on 18.6.01. As per P3 some medicines were administered and he was subjected to some laboratory test. So, the Lower forum is perfectly justified in holding that the complainant has failed to prove the expenses claimed by him. 6. The complainant was examined before the lower forum as PW1 and P1 to P5 documents were marked through him. In his testimoney, it is stated that P3 series are the hospital bills. It is pertinent to note at this juncture that the complainant as PW1 has not spoken anything about the expenses incurred by him in connection with his treatment in the hospitals. There is no whisper in his testimony with respect to the alleged expenses incurred by him. The Doctor who was attached the Mercy Hospital was examined a PW2. She has also not spoken to anything about the expenses incurred by the complainant/insured in-connection with his treatment at the Mercy Hospital, Valakom. Thus, there is no scrape of paper available on record to substantiate the case of the complainant regarding the expenses incurred by him for his treatment in the hospitals referred to in his complaint. At this juncture it is pertinent to note that the complainant has not produced any document evidencing his treatment in G.G.Hospital, Trivandrum and Cosmopolitan hospital, Trivandrum. Another matter to be noted at this juncture is production of photostate copies of some medical records with respect to the treatment of one Meryamma Ravelkutty at Srinarayana Trust Medical Mission, Kollam. The aforesaid documents issued from Sri Narayana Trust Medical Mission would show that sum of Rs.17114.50 was expended in connection with the treatment of Mrs.Meryamma Ravelkutty at Srinarayana Medical Mission Hospital. But the complainant has no case that he had undergone treatment in the aforesaid Srinarayana Trust Medical Mission Hospital. 7. P4 is copy of the repudiation letter dated 7.2.02 issued by the opposite party Insurance Company to the son of the complainant repudiating the Insurance claim in connection with the treatment of his father. P5 is copy of the certificate issued by PW2 stating that there occurred a mistake while issuing D2 medical certificate by the Senior Dr.Riyas Ahammed.M.D Physician, attached to Mercy Hospital Valakom. Thereby, P5 certificate is issued stating that the complainant Mr.C.Pappachan was suffering from diabetes for the past 10 months. But in D2 medical certificate it was certified that the complainant Mr.C.Pappachan is a known diabetic on drugs for past 10 years. The documentary evidence as well as the oral evidence adduced from the side of the complainant is totally silent about the expenses incurred in connection with the medical treatment of the complainant in various hospitals. The lower forum has rightly rejected the claim for Rs.31615.68/-. But the Lower forum has allowed the compensation of Rs.5000/- claimed by the complainant as compensation for deficiency of service on the part of the opposite party/insurance company with a cost of Rs.500/-. In effect there is no legally sustainable ground to modify the impugned order passed by the lower forum. Thus, the present appeal lacks, merits and deserves dismissal. The points are answered accordingly. In the result, the appeal is dismissed. The impugned order passed by the CDRF, Kollam in OP.76/02 is up-held. The appellant/complainant is directed to pay a sum of Rs.500/- as costs to the respondent/opposite party. SRI.M.V.VISWANATHAN -- JUDICIAL MEMBER SRI.S.CHANDRAMOHAN NAIR -- MEMBER S/L | 
