DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD
Dated this the 25th day of January 2014
Present: Smt.Seena.H. President
Smt.Shiny.P.R. Member
Smt.Suma.K.P. Member Date of Filing : 23/08/2013
CC No.141/2013
1.T.K.Sukumaran,
S/o.Kunchu,
Thoppil House,
Pampadi West,
Thiruvilwamala (PO),
Thrissur – 680 588
2.Sreeja Sukumaran,
W/o.Late T.K.Sukumaran,
Thoppil House, West Pampady,
Thiruvilwamala
3.Sree Lakshmi
D/o.Late T.K.Sukumaran,
Thoppil House, West Pampady,
Thiruvilwamala - Complainants
Vs
Branch Manager,
New India Assurance Company,
J.R.J.Complex,
Ottapalam Palakkad. - Opposite party
(By Adv.T.P.George)
O R D E R
Order by Smt.Shiny.P.R. Member
The complainants No. 2 & 3 herein are the legal heirs of deceased complainant No.1 impleaded as per order in IA/3774/13 dated 4/11/2013.
Complainant No.1 had taken an Universal Health Insurance Policy (Hospitalization Benefit Policy) as per Policy No. 76110334121900000126 for the period from 14/12/2012 to 13/12/2013. On 19/4/2013 complainant No.2 admitted in GEM Hospital, Thrissur for surgical removal of appendicitis and cyst in Ovary and discharged on 21/4/2013. An amount of Rs. 19,750/- was spent for treatment expenses. On 30/4/2013 claim form (Ext. A2) was filed before the opposite party to get the claim. On 18/7/2013 opposite party sent a registered letter (Ext. A3) to the complainant to inform that they are only liable to pay Rs. 4,870/- as per the conditions specified in the policy. The act of opposite party has resulted in huge financial loss and tremendous mental agony to the complainants. Hence the complaint.
In the version filed by the opposite party, they admitted the policy and medical bills. According to the conditions stipulated in the policy (Ext. B1) opposite party is liable to pay Rs. 150/- per day for Inpatient, 15% of the assured amount for Medical Practitioners consultant, Specialist fee, Nursing expenses and 15% of the assured amount for anasthesia, blood, oxygen, operation theatre charge, surgical appliances, medicines/drugs, diagnostic materials. In the policy there is a clause that total expenses incurred in any one illness is limited to Rs. 15,000/-. The opposite party disputes the receipt of Rs. 6,000/- dated 29/4/2013 which was issued by the surgeon. Their contention is that the receipt was without signature and name of the treated doctor. It was also belated one. Hence they are not liable to pay the same. At the same time they are ready to pay Rs. 4,870/- to the complainant. So they submitted that there is no deficiency in service from their part.
Both parties filed their chief affidavits and documents. Ext.A1 to Ext.A3 marked on the part of complainant and Ext. B1 to Ext.B3 marked on the side of opposite party.
Now the following issues are raised for consideration:
1. Whether there is any deficiency in service on the part of opposite party?
2. If so, what is the relief and cost complainants are entitled?
Issues 1 & 2
We perused the relevant documents on record. Opposite party admitted the policy and claim of Rs. 4,870/- for the total claim. As per Ext.B2 the Laproscopic, Apendicectomy and partial excision of the ovarian cyst Rt were done on 19/4/2013. Complainant spent Rs. 19,750/- for the treatment expenses including the surgery. On 29/4/2013 the surgeon issued a receipt of Rs. 6,000/- (Ext. B3) which is bearing seal of GEM Hospital and signature of surgeon. Ext.B2 shows that the surgery was done on 19/4/2013. In this circumstances we assume that the receipt is issued for this purpose. The patient was treated as Inpatient for 2 days. Hence in this case Rs. 300/- for 2 days Inpatient, Rs. 4,500/- for medical bills etc, Rs. 70 for consultation fee and Rs. 4,500/- for surgery fee etc are to be paid by opposite party. So it is found that the opposite party committed deficiency in service.
In the result, the complaint is partly allowed and the opposite party is directed to pay the treatment expenses of Rs. 9,370/- (Rupees Nine thousand three hundred and seventy only) and pay Rs. 1,000/- (Rupees One thousand only) as cost of the proceedings to the complainant within one month from the date of receipt of this order, failing which complainant is entitled for 9% interest for the whole amount from the date of order, till realization.
Pronounced in the open court on this the 25th day of January 2014.
Sd/-
Smt. Seena. H
President
Sd/-
Smt. Shiny.P.R.
Member
Sd/-
Smt. K.P.Suma.
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 – Photocopy of Insurance Policy 76110334121900000126
Ext.A2 – Photocopy of claim dated 30/4/13 for Rs.19,750/-
Ext.A3 – Photocopy of letter dated 18/7/13 issued to the complainant by opposite party
Exhibits marked on the side of opposite party
Ext.B1 – Attested copy of Policy Schedule and clause
Ext.B2 – Discharge Summary dated 21/4/2013 (original)
Ext.B3 – ReceiptNo.1879 dated 29/4/2013 (original)
