O R D E R

Sri. Santhosh Kesavanath P., President.

The case of the petitioner's is as follows:

The petitioner insured her daughter with the opposite party in 'Pravasi Insurance Policy' with valid policy No. 2001/47/60/162/81313. During the insured period, daughter of the petitioner, Anu John was admitted at Cherthala K.V.M Hospital, Medical College Hospital Alappuzha and Medical Trust Hospital, Ernakulam for the discease Viral Enephalities. According to the petitioner she had incured morethan Rs. 80000/- as treatment expeses towards purchase of medicine and hospitalisation expenses. The petitioner preferred a claim to the opposite party for an amount of Rs.41108/- to the first opposite party but the first opposite party had only given an amount of Rs. 25457/-. Petitioner states that with helding of part of the claim amount by the opposite party is an unfair trade practice and is clear deficiency on service So, she prays for an order directing the opposite party to pay the balance amount of Rs. 15651/- to the petitioner along with Rs. 10,000/- as compensation and cost of the proceedings.

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Opposite party entered appearance and filed version contenting that the petition is not maintainable. According to the opposite party liability of the Insurance Company is only as per the terms and conditions of the policy. The opposite party contented that the petitioner accepted the amount of Rs. 25,457/- as ful and final settlement of the claim so she is not entitled for any further amounts. Opposite party contented that some bill submitted by the petitioner are not allowable because of sufficient reason. So, opposite party stated that there is no deficiency of service on their part and the claim of he petitioner is repudiated on valid and sufficient reason. So, they pray for the dismissal of the petition.

Points for determinations are:

i) Whether there is deficiency in service on the part of the opposite party?

ii) Reliefs and costs.

Evidence in this case consists of affidavit filed by both parties and Ext. A1 document on the side of the petitioner and Ext. B1 to B4 documents on the side of the opposite party.

Point No. 1

Main question to be decided in this case is whether detaining part of the claim amount of the petitioner is for any valid reason or not. Opposite party in their version has given the reasons for deduction of the amount. Even though the opposite party had in detail stated explanations in their version for not allowing the claim of the petitioner. We are of the opinion that the said reasons are not sustainable, opposite party produced

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the conditions of the policy and the said document is marked as Ext. B1. In Ext. B1 it is stated that as per the Kudumba Arogya Scheme company shall reimburse to the insured person the amount of such expenses as are reasonably and necessarily incured in respect there of by or on behalf of the such insured person. Here the opposite party produced the bills. Showing the expenses incurred to the petitioner and the said document is marked as Ext. B2 we are of the opinion that the claim of the petitioner on the basis of bills is genuine. The stand taken by the opposite party with regard to non issuance of certain bills like non-mentioning of date, registration fee, taxy charge etc. are not at all acceptable because as per policy condition the opposite party is liable to reimburse to the insured person the amount of such expenses. Further more the opposite party has not produced any contra evidence to prove that the said bills are concoted documents. Even though the petitioner had claimed the post hospitalisation treatment expenses in the tune of Rs.1988.57. She has not adduced any evidence to show the same so the said claim of the petition is not allowable. So we are of the opinion that the act of the opposite party in partly allowing the claim of the petitioner is a clear deficiency of service. Point No. 1 is found accordingly.

Point No. 2

In view of finding point No. 1 , petition is to be allowed and the petitioner is entitled for the reliefs sought for. In the result the opposite party is ordered to pay the petitioner an amount of Rs.15651/- Defanitely due to withhelding of a part of the claim of the petitioner has caused loss and suffering to the petitioner. So, we direct the opposite party to pay of Rs. 5000/- as compensationd to the petitioner and pay

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an amount of Rs. 1,000/- as cost of the proceedings. Order shall be complied with within 30 days of receipt of this order.

Dictated by me trascribed by the Confidentiaal Assistant corrected by me and Pronounced in the Open Forum on this the 28^th day of October, 2008.