2. The opposite party filed a written version. In that they have admitted that the opposite party had issued a "Santhwana Insurance Policy" bearing No.101102//48/03/00532 for the peiod of insurance 26/08/2003 to 25/08/2004 in the name of the complainant. As per condition No.VII of the policy, the policy would cover re-admission in the hospital only if such re-admission is warranted and directly arising out of the accident occurred to the insured, provided that the re-admission into hospital is within 6 months from the date of accident. The complainant came to the opposite party's Thodupuzha Branch Office for claiming expenses for re-admission in hospital, which was after more than two years from the date of accident. The Thodupuzha Branch Manager met the complainant and pointed out the relevant condition in the policy. Complainant was convinced and he left the office without making any application as alleged in the complaint. As the complainant had not filed an application or claim, the opposite party had no occasion to repudiate the claim. The present complaint is filed as an experiment only and so the complaint is not maintainable.
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 P5 marked on the side of the complainant and the oral testimony of DW1 on the side of the opposite party.
5. The POINT :- There is no dispute regarding the insurance policy of the complainant. The opposite party admitted that the petitioner was having valued insurance policy at the time of accident. The petitioner is a consumer in all means. The opposite party disbursed an amount of Rs.13,000/- to the complainant for the medical expenses incured in the accident occurred to the complainant. But after that they are not liable for the expenses for the further treatment after 6months. It is a violation of the policy condition No.VII. The policy would cover re-admission in the hospital only if such re-admission is warranted and directly arising out of the accident occurred to the insured, provided that the re-admission in the hospital is within 6 months from the date of accident. Ext.P1 is the policy certificate produced by PW1 who is the complainant. It was renewed in every year. Ext.P2 is the treatment certificate issued by the doctor from the Chazhikattu Hospital, Thodupuzha. Ext.P3 is the medical bill of the complainant when he was admitted in the hospital in the second time for the removal of the implant. Ext.P4 is the policy certificate at the time of accident, which is produced by the respondent. Ext.P5 is the policy certificate of the complainant for the period 3.09.2005 to 2.09.2006. As per Ext.P2, which is a treatment certificate produced by PW1, there was a fracture on the right tibia of the complainant due to the accident. A surgery was done on 27/03/2004 and he was discharged after treatment. Again the complainant was admitted in the same hospital and the steel screws implanted on 27/03/2004 were removed by a surgery under spinal anaesthesia. It clarifies that both surgeries were done due to the fracture caused on the same accident. The re-admission for the second surgery was warranted and was directly arised out of the accident occurred to the insured. There is no reason to disbelieve Ext.P3, the medical bills produced by the complainant. Condition VII of the policy states that " the cover under weekly payment section would be provided only during the period of actual Hospitalisation as inpatient. The policy would cover re-admission in the hospital only if such re-admission is warranted and directly arising out of the accident occurred to the insured, provided that the re-admission into hospital is within 6 months from the date of accident". In this case re-admission is in order to remove the implanted screws and which is highly necessary and was directly arising out of the accident which is a part of the surgery done on 27/03/2004. So the repudiation of the claim by the opposite party only because of the reason that the re-admission into the hospital was not within 6 months is not fair. As per the evidence of PW1, the second surgery can be done only when the pain comes. The re-admission for second surgery was done after 2 years is duly because of the advice of the Surgeon and not because of any laches on the part of the complainant. So repudiating the claim on the ground of the limitation of time is a gross deficiency on the part of the opposite party. The complainant's right for filing a petition before the MACT is also lost by this. The reported decision from our Hon'ble High court in 2004(3)KLT page 2007, Chacko Vs. Abdul Rahman says that Motor Vehicles Act 1988, Section 168 - Compensation for injuries suffered in a motor accident - future expenses for treatment can be awarded. So we think that the complainant is entitled to get the medical expenses of the re-admission. The medical bills costs an amount of Rs.4,967/- which is nearly Rs.5,000/-.
In the result, the petition allowed. The opposite party is directed to pay Rs.5,000/- to the petitioner with 12% interest from the date of this petition along with Rs.500/- the cost of the petition within one month of receipt of a copy of this order, failing which the outstanding amount shall carry another 12% interest from the date of default.
Pronounced in the Open Forum on this the 16th day of June, 2008
