Kerala

Kollam

CC/07/323

Sulfikar,Thenkachyil Veedu,Park Mukku,Kottiyam - Complainant(s)

Versus

The Branch Manager,Life India, Near Upasana Hospital, Kadappakkada - Opp.Party(s)

30 Nov 2009

ORDER


C.D.R.F. KOLLAM : CIVIL STATION - 691013
CONSUMER DISPUTES REDRESSAL FORUM ::: KOLLAM
consumer case(CC) No. CC/07/323

Sulfikar,Thenkachyil Veedu,Park Mukku,Kottiyam
...........Appellant(s)

Vs.

The Branch Manager,Life India, Near Upasana Hospital, Kadappakkada
National Insurance Company,Aluva Divisional Office,Urumbathu Building,Pump Junction, Aluva
...........Respondent(s)


BEFORE:


Complainant(s)/Appellant(s):


OppositeParty/Respondent(s):


OppositeParty/Respondent(s):


OppositeParty/Respondent(s):




ORDER

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SRI.K. VIJAYAKUMARAN, PRESIDENT.

 

            This is a complaint  seeking insurance claim, compensation  and costs

The averments in the complaint can be briefly summarized as follows:

 

The complainant’s son joined   a medical Insurance Policy  of 1st opp.party for Rs. 30,000/- with No.263273 in his name and policy No.209655 for Rs.20,000/- in  his name  paying respectively Rs. 300/- and 200/- towards premium.   His son sustained injury consequent on a fall on 8.5.06  and had undergone treatment  as inpatient at the Upasana Hospital, Kollam and discharged on 24.5.06.   The complainant thereafter filed claim petition through the first opp.party for the expenses incurred for the treatment of his son, amounting to Rs.13,641/- with the bills but the same were returned stating that they are duplicate bills.   Thereafter they repudiated the claim which is illegal.  Hence the complaint.

The 1st opp.party filed version contending, interalia, that the complaint is not maintainable either in law or on facts.   The complainant applied to the 1st opp.party for membership under the scheme offered by 1st opp.party.   The membership was given and the complainant taken membership after accepting all terms and conditions.  The 1st opp.party entered into an agreement with opp.party 2 as per which opp.party 2  will  insure member of opp.party 1.  The 1st opp.party insured the complainant with opp.party 2 subject to terms and conditions.   The policy assured a sum of Rs.5000/- for mediclaim and Rs.10,000/- for personal accident  benefit.  The 1st opp.party is not a party to the dispute.   The roll played by 1st opp.party  is only insured.   The complainant as a corporate agent  of opp.party 2.   The 1st opp.party is not liable to pay the amount.   There is no deficiency in service on the part of the 1st  opp.party.  Hence 1st opp.party prays to dismiss the complaint.

2nd opp.party filed version also contending, interalia, that the complaint is not maintainable either in law or on facts.  The complainant is not a consumer.  The complainant has approached this Forum with unclean hands.  It is admitted that the opp.party had entered into a Master Policy agreement with the first opp.party covering  the risk of the members who obtained Health Care membership certificate from the1st opp.party subject  to the terms and conditions of the Master Policy Agreement.  As per the master policy agreement the health care certificate holders covered under the policy are eligible to claim a maximum medical benefit of Rs. 5,000/-during the policy period towards treatment expenses   As per the terms of the policy agreement  certificate holders who are claiming  the medical benefit under the scheme shall produce the original medical and treatment bills and records.  As per the policy conditions the 2nd opp.party is liable to indemnify the insured only on production of the original bills against which the claim is preferred.   The complainant has preferred a claim with the opp.party claiming  medical reimbursement of Rs.13,641/- alleged to have been incurred by the complainant in connection with the treatment of his son at Upasana Hospital, Kollam.  The medical bills produced by the complainant  except for an amount of Rs.1524/-  were found  to be duplicate bills.  Since the medical bills produced are duplicate bills, this opp.party inform the complainant about the difficulty in settling the claim for want of  the original bills.  It was further informed that they are willing to settle the amount or Rs.1524/- against which originals bills are produced.  A discharge voucher was also issued to  the complainant for Rs. 1524/-against which the complainant produced original bills but the same was  not returned.  The opp.party is ready to consider the balance claim subject to the maximum of Rs.5000/- in the event of  production  of the original bills.  Since the original bills as well as the discharge voucher not returned the claim was repudiated.   There is no deficiency in service on the part of the 2nd opp.party.  Hence they alsoprays to dismiss the complaint.

Points that would arise for consideration are:

1.     Whether the complainant is entitled to get re-imbursement as prayed for

2.     Whether there is deficiency in service on the part of the opp.party

3.     Reliefs and costs.

For the complainant PW.1 is examined.  P1 to P3 series are marked.

For the opp.party DW.1 is examined.   Ext. D1 to D5 are marked.

POINTS;

As  a matter of fact the policy is admitted.  There is also no serious dispute that the complainant is entitled to get Rs.5000/- towards medical expe4nses had he produced all original bills.   According to the opp.parties they have admitted claim for Rs.1524/- , wherein original bills have been produced and with regard to the balance amount they are ready to pay the amount on producing the original bills instead of duplicate bills

 

          According to the complainant he has produced all original bills whereas the definite case of opp.parties is that a major portion of the bills received by them   are duplicate bills.   Though the complainant would contend  that the word duplicate was made by the opp.parties there is absolutely no evidence  to support  that contention.   The learned counsel for the opp.party would advance an  argument that the original bills might have been used by the complainant for some other purpose.   But that argument is also not supported by any material.  It cannot be believed that the complainant would practice fraud or  foul play for such a meager sum especially when he has produced original bills for Rs.1524/- .   The  1st p[[.party has not disputed that the complainant is entitled to get Rs.5000/-  as compensation provided he produced original bills.  The inability to produce all original bills  as pointed out earlier cannot  be said to be due to any fraud or foul play.   So in our view it is only just and proper to allow the claim especially in view of the fact that the disputed amount is only a meager sum.   Therefore we are inclined to allow the complaint.

 

          According to the opp.parties  the complainant has not produced the original bills before them  along with the claim and for considering the claim original bills are essential as per the terms and conditions  of the policy.  The complainant admittedly has not produced the original bills.  In these circumstance  the conduct of the opp.party in repudiating the claim cannot be attributed  to any deficiency in service.  The complainant who failed to produce the original bills cannot claim compensation alleging deficiency in service.   For all that has been discussed above we hold that the complaint is entitled to get Rs.5,000/- which is the maximum amount admissible as per the policy conditions.  Point found accordingly.

 

In the result the complaint is allowed setting aside the repudiation and directing the opp.party to pay the complainant Rs.1524/-  receiving the original bills and Rs.3476/-receiving the duplicate bills.  We direct the parties to suffer their costs.   The order is to be complied with within one month from the date of this order.

Dated this the 30th day of November, 2009.

.

I N D E X

List of witnesses for the complainant

PW.1. – Abdul Jabbar

List of documents for the complainant

P1. – Repudiation letter

P2. – Policy certificate

P3. – Photocopy of Bills

List of witnesses for the opp.party

DW.1. – K. Radhakrishnan

List of documents for the opp.party

D1. – Membership certificate

D2. – Letter sent by Insurance co. to the complainant dated 10..6.06

D3. – Reply notice

D4. – Letter sent by complainant to the Divisional Manater dated 15.3.2007

D5. – Letter sent by Insurance company to the complainant dated 19.3.2007.