BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI

Dated this the 30th day of March, 2009

Present:

SRI.LAIJU RAMAKRISHNAN PRESIDENT

SMT.SHEELA JACOB MEMBER

SMT.BINDU SOMAN MEMBER

C.C No.182/2008

Between

Complainant : K.N.Mohanan,

Kallookkarottu House,

Nariyampara P.O,

Idukki District.

(By Adv: V.C.Sebastian)

And

Opposite Party : The Branch Manager,

New India Assurance Company Limited, Kattappana P.O,

Idukki District - 685 508.

(By Adv: K.Pradeepkumar)

O R D E R

SMT.SHEELA JACOB(MEMBER)

The complainant joined a Hospitalization benefit policy covering the period 19.10.2007 to 18.10.2008 launched by the opposite party. The policy includes hospitalization expenses and medi-claim to the tune of Rs.50,000/-. As per the policy, the complainant and his family would get the benefits. The policy Number is 761503/34/07/14/00000299. He paid Rs.3,337/- to the opposite party as premium on 19.10.2007. On 15.05.2008 the complainant's wife was admitted in the Medical Trust Hospital, Ernakulam due to back pain and had undergone treatment as inpatient. An operation was conducted there. The medical expense amounted to Rs.83,479/-. The opposite party had paid Rs.25,000/- to the hospital as advance. As per the policy, the opposite party is bound to pay Rs.50,000/-. Though a claim was made to the opposite party they have given only Rs.25,000/-. Balance amount Rs.25,000/- was not paid. Alleging deficiency in service, the complaint has been filed for a direction to pay Rs.25,000/- with interest and also compensation for deficiency in service.

2. The opposite party filed a written version admitting the insurance policy. It is a hospitalization benefit policy for the period 19.10.2007 to 18.10.2008. It is contended that the opposite party is not liable to pay the sum assured amount of Rs.50,000/-. As per the policy condition, (the opposite party is liable) the maximum amount payable is only Rs.31,500/-, out of which the opposite party was paid Rs.25,000/- to the hospital as advance and the opposite party is ready to pay the balance amount of Rs.6,500/-. So far as the complainant did not submit the proper claim form. So there is no deficiency in service on their part.

3. The point for consideration is whether there was any deficiency in service on the part of the opposite party, and if so, for what relief the complainant is entitled to ?

4. The evidence consists of the oral testimony of PW1 and Exts.P1 to P3 marked on the side of the complainant and the oral testimony of DW1 and Ext.R1 marked on the side of the opposite party.

5. The POINT :- The claim is admitted. The claim relates to the hospitalization benefit policy by the complainant for the period from 19.10.2007 to 18.10.2008. The complainant was examined as PW1. The complainant has produced copy of the insurance policy at the time of evidence is marked as Ext.P1. Discharge summary is marked as Ext.P2. The bill is marked as Ext.P3. The total amount of Ext.P3 bill is Rs.83,479/-. In cross examination, PW1 has admitted that the claim form was not produced and stated that the opposite party, paid Rs.25,000/- to the hospital as advance. The opposite party was examined as DW1. The opposite party has produced the policy condition at the time of evidence and is marked as Ext.R1. He has stated that the complainant did not give the claim form, discharge summary and bills. But in cross examination, DW1 has admitted that they did not send any notice to the complainant to produce the documents. In Ext.R1 which is a Janata Medi-claim policy condition. But the complainant joined in the hospitalization benefit policy. In Ext.P1 policy the sum assured is Rs.50,000/-. Therefore the rejection of the claim is on unreasonable grounds and amounts to deficiency in service. So the opposite party is bound to pay the eligible compensation of Rs.50,000/- as evidenced by Ext.P3 bill, Rs.83,479/-. The opposite party has paid Rs.25,000/- to the hospital as advance. So the opposite party is bound to pay Rs.25,000/- being the balance of admissible insurance amount with 12% interest from the date of petition. Considering the nature of the case, we think it will be reasonable to fix Rs.1,500/- by way of compensation for deficiency in service. The complainant is also entitled to the cost of this petition which we would fix at Rs.1,000/-.

In the result, the opposite party is directed to pay to the complainant Rs.25,000/- being the admissible insurance amount with 12% interest from the date of this petition and Rs.2,500/- as costs and compensation of this petition within 30 days of receipt of a copy of this order, failing which the amount shall carry 12% interest per annum from the date of default.

Pronounced in the Open Forum on this the 30th day of March, 2009

Sd/-

SHEELA JACOB(MEMBER)

Sd/-

I agree SRI.LAIJU RAMAKRISHNAN(PRESIDENT)

Sd/-

I agree SMT.BINDU SOMAN(MEMBER)

APPENDIX

Depositions :

On the side of Complainant :

PW1 - K.N.Mohanan

On the side of Opposite Party :

DW1 - Jose.F.George

Exhibits:

On the side of Complainant:

Ext.P1 - True copy of Insurance Policy

Ext.P2 - True copy of Discharge Summary issued by the Medical Trust

Hospital, Ernakulam

Ext.P3 - True copy of Medical Bills issued by the Medical Trust Hospital,

Ernakulam

On the side of Opposite Party :

Ext.R1 - Janata Medi-claim Policy with Conditions