IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 28th day of May, 2012.
Present : Sri. Jacob Stephen (President)
Sri. N. Premkumar (Member)
Smt. K.P. Padmasree (Member)
C.C.No.19/2012 (Filed on (11.01.2012)
Between:
K. Balan,
Muthangamuruppel House,
Payyanamon.P.O.,
Konni – 689692,
Pathanamthitta Dist. ….. Complainant
And:
1. The Branch Manager,
National Insurance Co. Ltd.,
Branch Office, Pathanamthitta,
P.B.No.67, Kallumthara Building,
Near General Hospital,
Main Road, Pathanamthitta,
Pin – 689 645.
(By Adv. P.D. Varghese)
2. M/s. TTK Health Service Private Ltd.,
1400-B, Mareena Building,
M.G. Road, Ernakulam,
Kochi – 682 016. ….. Opposite parties.
O R D E R
Smt. K.P. Padmasree (Member):
The complainant K. Balan, Muthangamuruppil House, Payyanamon.P.O., Konni has filed this complaint against the opposite parties for getting a relief from the Forum.
2. The complainant’s case is as follows: Opposite parties issued a medi claim insurance policy No.571402/48/10/8500000789 in the name of the complainant and his family for a period from 09.10.2010 to 08.10.2011. On 15.09.2011 the complainant admitted at Muthoot Hospital, Pathanamthitta and got discharged on 17.09.2011. The total hospital bill is ` 4,227. Hospital authorities sent pre-authorization letter to medi claim office. But they didn’t give any reply. So the complainant remitted the total hospital bill at the time of discharge. After that the complainant had lodged a claim form along with all records for getting the medical expense incurred by him. Then the opposite party demanded the discharge summary of a previous operation done for the complainant in 2007 and the complainant send the same. After that there is no reply or response from the side of the opposite parties. So the complainant sent a registered letter enquiring the reason for non-payment of the claim. But there is no reply from the opposite parties. The non-payment of the medical expense of the complainant during the coverage period is a deficiency of service from the opposite parties and due to the said deficiency of service the complainant sustained financial loss and other inconveniences. For that the opposite parties are liable to the complainant. Therefore he filed this complaint for getting the medical reimbursement amount along with compensation and cost.
3. The 1st opposite party entered appearance and filed their version. 2nd opposite party is exparte. The 1st opposite party admitted that a medi calim policy was issued in favour of the complainant for a period from 09.10.2010 to 08.10.2011. But the opposite party denies their liability to compensate the applicant due to the violation of the policy conditions.
4. The complainant has submitted a claim for ` 4,227 as the hospitalization expenses of the complainant from 15.09.2011 to 17.09.2011 to the 2nd opposite party M/s. TTK Health Services Pvt. Ltd., Ernakulam who is the administrator of the 1st opposite party. It is revealed from the claim form that the complainant had undergone S/P Laparoscopic Cholecystectomy during 2007. The 2nd opposite party requested the complainant to submit the discharge summary of his previous surgery. Thereafter the complainant submitted the discharge summary without other details and hence the claim could not be settled. The opposite parties states that so far the claim of the complainant is not repudiated and the claim is premature and liable to be repudiated for the above reason. The 1st opposite party canvassed for the dismissal of the complaint on the basis of this version.
5. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?
6. The evidence of this complaint consists of the oral testimony of PW1 and Exts.A1 to A5(a). There is no oral or documentary evidence from the part of the opposite parties. But they cross examined the complainant. After closure of evidence, both sides were heard.
7. The Point:- Complainant’s allegation is that opposite parties denied his medi claim though he is entitled to get the claim. In order to prove his case, complainant adduced oral evidence as PW1 and produced certain documents. The documents produced were marked as Exts.A1 to A5 series. Ext.A1 is the photocopy of policy schedule dated 17.09.2010. Ext.A2 is the photocopy of discharge summary from MGM Muthoot Medical Centre, Pathanamthitta. Ext.A3 is the photocopy of letter sent by the second opposite party to the complainant. Ext.A4 is the photocopy of discharge summary dated 08.05.2008 issued by Escorts Hospital & Research Centre Ltd., Faridabad. Ext.A4(a) is the postal receipt of Ext. A4 dated 18.10.2011. Ext.A5 is the photocopy of reminder letter sent to the second opposite party by the complainant dated 16.11.2011. Ext.A5(a) is the postal receipt of Ext. A5 dated 16.11.2011.
8. There is no oral or documentary evidence from the side of the opposite party.
9. On a perusal of the entire evidence adduced by both parties it can be seen that the complainant hold a valid medi claim policy during the period of treatment. It is pertinent to note that the 1st opposite party admitted that the complainant’s claim is not yet repudiated and the only contention is that the procedural formalities are not complied by the complainant and because of that the claim was not settled. It is also found that opposite parties has not made any proper intimation to the complainant for complying the formalities required for allowing the claim. So the non-payment of the complainant’s claim is a deficiency of services and the opposite parties are liable to compensate the complainant. In this circumstance, the complainant’s prayer can be allowed.
10. In the result, this complaint is allowed, thereby the opposite parties are directed to pay an amount of ` 4,227 (Rupees Four Thousand Two hundred and twenty seven only) as the reimbursement of medical expenses along with ` 1,000 (Rupees One Thousand only) as compensation and ` 500 (Rupees Five hundred only) as cost to the complainant within 15 days from the date of receipt of this order, failing which the complainant is allowed to realize the whole amount with 9% interest from today till the realization of the whole amount.
Declared in the Open Forum on this the 28th day of May, 2012.
(Sd/-)
K.P. Padmasree,
(Member)
Sri. Jacob Stephen (President) : (Sd/-)
Sri. N. Premkumar (Member) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : K. Balan
Exhibits marked on the side of the complainant:
A1 : Photocopy of policy schedule dated 17.09.2010.
A2 : Photocopy of discharge summary dated 17.09.2011issued by
MGM Muthoot Medical Centre to the complainant.
A3 : Photocopy of letter dated 12.10.2011 sent by TTK Health Care
to the complainant.
A4 : Photocopy of discharge summary dated 08.05.2008 issued
from Escorts Hospital & Research Centre, Faridabad.
A4(a) : Postal receipt of Ext. A4.
A5 : Photocopy of reminder letter dated 16.11.2011 sent to the
opposite party to the complainant.
A5(a) : Postal receipt of Ext. A5 letter.
Witness examined on the side of the opposite parties: Nil.
Exhibits marked on the side of the opposite parties: Nil.
(By Order)
(Sd/-)
Senior Superintendent.
Copy to:- (1) K. Balan, Muthangamuruppel House,Payyanamon.P.O.,
Konni – 689692, Pathanamthitta Dist. (2) The Branch Manager, National Insurance Co. Ltd.,
Branch Office, Pathanamthitta,P.B.No.67, Kallumthara
Building, Near General Hospital, Main Road,
Pathanamthitta, Pin – 689 645.
(3) M/s. TTK Health Service Private Ltd.,1400-B,
Mareena Building, M.G. Road, Ernakulam,
Kochi – 682 016.
(4) The Stock File.
