`  DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  9^th day of  June, 2023 

Present      :    Sri. Vinay Menon V., President

                  :   Smt. Vidya A., Member                       

                  :   Sri. Krishnankutty N.K., Member                               Date of Filing: 28/04/2022  

                         CC/74/2022

Sunil P,

S/o. K.G.Panikkar,

Flat No.1B, Classic Legacy Apartments,

New Civil Nagar, Palakkad – 678 001                                    -                       Complainant

(By Adv. V. Sujith)

                                                                                                Vs

The Branch Manager,

M/s. Star Health & Allied Insurance Co. Ltd.,

Branch Office, 1^st Floor,

R.K. Buildings, Opp. Chitturkavu,

Chittur, Palakkad – 678 101                                       -                       Opposite party

(O.P.by Adv. M/s. Ratnavally P. & Kiran G. Raj A.)

O R D E R

By  Sri. Vinay Menon V., President

1. Complainant pleads that he is a beneficiary under a health insurance policy issued by the opposite party and that there is a coverage to a tune of Rs.4,00,000/-. Complainant’s wife underwent treatment for leukemia and had to expend Rs.14,78, 961/-. Since the sum assured is Rs.4,00,000/-, the complaint is entitled to receive the entire sum. But the O.P. indemnified the complainant only to a tune of Rs. 2,00,000/-. O.P. repudiated his claim for balance amount. Aggrieved by the non- payment of balance amount, this complaint is filed.
2. Even though notice was received by the opposite party, they failed to file their version within the statutory period hence the remaining proceedings were  ex-parte.
3. In the absence of any counter pleadings, it is only incumbent upon the complainant that he proves that a prima facie case exists in his favour.
4. Evidence on the part of complainant comprised of proof affidavit and Ext.A1 to A4. Ext. A1 is the schedule of the insurance policy unaccompanied by the terms and conditions. Ext.A2 is the discharge summary dated 9/8/2021. Ext.A3 is a final bill. Ext.A4 is a communication dated Nil issued by the opposite party rejecting the claim for balance 2,00,000/-.
5. In the facts and circumstances of the case the evidence that was necessary to prove the contentions of the complainant was that he was entitled to the balance Rs. 2,00,000/-. Merely because of the opposite party was precluded from filing of version we are unable to come to a conclusion that the complainant is entitled to the balance amount. 
6. The available documents prove that there existed a subsisting policy for Rs.4,00,000/- and that the opposite parties had made payments of Rs. 2,00,000/- out of the sum insured of Rs. 4,00,000/-.

The complainant has not even produced the entire policy schedule so that this Commission can go through the terms and conditions under which the policy was issued. Even if the complainant took pains to get the medical records they submitted before the company produced before this Commission, they failed to get the documents that would show the calculations or the raison d’ etre for allowing only part payment. We cannot arrive at a studied conclusion or even pre-ponder a probability based on the available evidence.

7. Hence, to that extend this complaint is dismissed.
8. But at this juncture it would be pertinent to note that the claim for  balance amount made by the complainant was rejected by the opposite party by way of Ext.A4 communication. Ext.A4 communication is a non speaking reply. When a consumer approaches a service provider, especially one who is dealing with public monies, they are bound to provide reasoned reply with cogent reasons that are backed by documents that prove or at least highlight the mode of calculation adopted by the opposite party. Here the opposite party has rejected the claim of the complainant by a non speaking reply which is detrimental to the bonafide interest of the complainant. This in our opinion is an unfair trade practice.
9. In view of our finding that there is deficiency in service on the part of the opposite party in providing a non-speaking reply, we hold that the complainant is entitled to compensation and cost as herein below:

1. Compensation for unfair trade practice   -           Rs.50,000/-
2. Cost                                                           -           Rs.25,000/-
3. Period of compliance is 45 days failing which the complainant would become entitled to solatium of Rs. 250/- per month or part thereof until the date of final settlement of the amounts stated above.

                  Pronounced in open court on this the 9^th  day of June, 2023.       

                                                                                                                               Sd/-   

                                                                                                            Vinay Menon V

                                                                President

                    Sd/-

              Vidya.A

                                   Member        

        Sd/-                                            Krishnankutty N.K.

                                                                                                                     Member

APPENDIX

Exhibits marked on the side of the complainant :

 Ext.A1 – Copy of Schedule of policy bearing No.P/181226/01/2021/003981

Ext.A2 – Copy of discharge summary dated 9/8/2021

Ext.A3 – Copy of Final bill dated 9/8/2021

Ext.A4 – Copy of communication dated Nil

Exhibits marked on the side of the opposite party:   Nil

Court Exhibit:  Nil

Third party documents:  Nil

Witness examined on the side of the complainant: Nil

Witness examined on the side of the opposite party:  Nil

Court Witness: Nil

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.