CONSUMER DISPUTES REDRESSAL FORUM
PALAKKAD, KERALA
Dated this the 16th day of February, 2013.
Present: Smt. Seena. H, President
: Smt. Preetha. G. Nair, Member
: Smt. Bhanumathi. A.K, Member Date of filing: 18/04/2012
CC /74/2012
A.C. Prasad,
S/o. Kannan, Arayanparamb house, - Complainant
Nagaripuram P.O, Mannur,
Palakkad Taluk, Palakkad.
(By Adv.T.U. Shaik Abdulla)
Vs
1. The Chairman,
Life India Education and Charitable Trust,
Surya Complex, Vellurkunnam, - Opposite parties
Muvattupuzha, Ernakulam.
( By Adv. Viju Chakkalackan)
2. The Manager,
The National Insurance Co. Ltd.,
Divisional Office, Urumbath building,
Pump Junction, Aluva – 683 101
( By Adv. P.K. Devadas)
3. Administrator,
M/s. TTK Health Care, TPA Private Limited,
1400 B, Mareena Building, M.G. Road,
Ernakulam, Cochin – 682 016
O R D E R
BY SMT. BHANUMATHI. A.K, MEMBER
complaint in brief :-
The complainant has taken a mediclaim certificate from 1st opposite party on 23/10/2009 paying an amount of Rs. 2,200/-. After few months the complainant experienced loss of hearing and as per the instruction of opposite party no. 1 he got admitted in the West Fort Hospital, Trichur and underwent surgery. The complainant was informed that the whole amount will be reimbursed by opposite parties on submitting necessary documents and claimform. Accordingly the complainant submitted the entire documents as the original bills treatment certificates, discharge summary along with the claimform to the opposite party. Several times the complainant approached the opposite party for getting the claim amount. At last the complainant sent a lawyer notice on 20/04/2011 demanding an amount of Rs. 76,698/-.
Opposite party no.1 informed the complainant over telephone that the claim amount will be disbursed soon. But it is not received.
So the complainant seeking an order directing the opposite parties to pay an amount of Rs. 26,698/- as medical expense and Rs. 50,000/- as compensation along with the cost of the proceedings.
1st and 2nd opposite party entered appearance and filed version. 3rd opposite party set exparte.
Opposite party no.1 admits that the complainant is a member of Life India Educational and Charitable Trust. 1st opposite party would honour the claim of the complainant as and when the claim application along with bills and other documents produced before them. It is true that the claim application given by the complainant was submitted by the 1st opposite party before the 2nd opposite party on 10/04/2010. The service made by the 1st opposite party ends there with. The 1st opposite party is not responsible to pay any treatment expenses as stated in the complaint.
Opposite pary no. 2 also admitted the policy. Opposite party no. 2 submits that whenever a claim is made 3rd opposite party has to collect all necessary documents connected with the matter, verify and settle if it is settleable or else inform the 2nd opposite party if it is not settleable showing reasons. But the 2nd opposite party has not been intimated anything about this claim before receiving the notice from the Forum. Opposite party no.2 says that as per the information given by Third party Administrator, M/s. TTK that the complaianant was suffering from Otosclerosis a degenerative ear disease of chronic nature and had sent a letter dated. 23/04/2010 to the complainant asking to furnish a certificate from the treating doctor stating the exact duration of defective hearing. The complainant has not responded to this letter.
Opposite pary no. 2 also submits tha the complainant had his first consultation at West Fort Hospital, Trichur on 21/02/2007 at ENT department with
Dr. Ram Mohan, ENT consultant who is the same doctor who has treated him. A reference letter dtd. 21/02/2007 from Ephphatha Speech & Hearing Centre, 32/210, Near St. Josephs Church, Punkunnam, Trichur, is kept in the Medical Chart sent by one Manju to the doctor stating “ Herewith referring Mr. Prasad, 41 years of age, who has Bil Otosclerosis with Mixed HL for expert opinion regarding surgery if favourable or not” .
As per the exclusions 5.1.1 of the Master Policy agreement all deceases/injuries which are pre-existing when the cover incepts for the first time the company will not be liable to make any payment under this policy. As the illness of the complainant was pre-existing one the company is not liable to make any payment. There is no deficiency of service on the party of 2nd opposite party. Complaint is liable to be dismissed.
Both parties filed their respective affidavits. Ext. A1 to A7 and B1 to B3 marked.
Heard the opposite party
Issues to be considered are
1. Whether there is any deficiency of service on the part of opposite party ?
If so what is the relief and cost?
Issues I and II
Complainant is alleging deficiency of service on the part of opposite parties in not disbursing of the amount claimed by him. Complainant became a member of opposite party no. 1 paying an amount of Rs. 2,200/- to it and received a medi claim certificate on 23/10/2009. After a few months the complainant experienced loss of hearing and as per the instruction of oppoisite party no.1 he got admitted in the West Fort Hospital, Trichur and under went surgery. For the same he expended an amount of Rs. 26,698/-. As per the instruction of opposite party no.1 he had submitted the claim form with all relevent document to opposite party no.1. As there is no reply from the opposite party the complainant enquired about the same at several times. But he did not get a correct reply. So on 20/04/2011 the complainant sent a lawyer notice to the opposite party no.1. No reply received. Opposite party no.1 and opposite pary no.2 filed version. Opposite party no.3 remains exparte.
The policy is admitted by the opposite parties. According to opposite party no.1 they have received the claim application and other records submitted by the complainant and forwarded them to opposite party no.2 on 6/05/2010 for Rs. 26,698/-. In Ext. B3 it is writtern as “ Received above three files and sent to TTK on 13/04/2010.”. The file of the complainant also included in the above three files. In Ext. B3 opposite party no.2 has fixed their seal also.
Opposite party no.2 says that the complainant has not responded to the letter dtd. 23/04/2010 sent by opposite party no.3 demanding him to furnish a certificate from the treating doctor stating the exact duration of defective hearing. There is no evidence to show the same. It is also not aware that whether the said letter was issued before or after submitting the claim form and documents by the complainant as the claim form of the complainant doesn't carry any date. According to opposite party no.2 whenever a claim is made TPA has to collect all the necessary documents connected with the matter and verify the same and settle it if its is settleable or else inform as if it is not settleable showing reason as per the terms and conditions enumerated in the contract with TPA. But opposite party no.2 has not intimated anything about this claim before receiving the notice from this Forum. So opposite party no.2 has not repudiated the claim of the complainant.
Opposite party no.2 contents that as per the exclusions 5.1.1 of the master policy agreement deseases/injuries which are pre-existing when the cover incepts for the first time the company will not be liable to make any payment under the policy.
Ext. B2 document dtd. 21/02/2007 that the complainant had undergone treatment at Ephphatha Speech of Hearing Centre, Punkunnam, Trichur. The name of the treated doctor is not seen in B2 document. Any how it is before taking the policy. The said document marked without any objection.
The complainant not present for examination at four occasions. Eventhough sufficient time was granted the complainant was not heard also. So that there is no sufficient evidence to consider the claim amount of the complainant.
But the opposite party has admitted that they have never repudiated the claim. The complainant sent lawyer notice dtd. 20/04/2011 to opposite party no.1 to know about the claim. So that it is sure that the complainant had submitted the claim application before 20/04/2011. Even after the complainant has not received any information from opposite parties regarding the claim. According to opposite party no.1 they have sent reply. But no document is produced to show the same.
From the above discussions we are of the view that there is deficiency of serivice on the part of opposite parties.
In the result complaint partly allowed. Opposite paries 1,2,3 are jointly and severally directed to pay an amount of Rs. 4,000/- ( Rupees Four thousand only) as compensation for delay caused in getting information regarding the claim from the opposite parties and Rs. 1000/- ( Rupees One thousand only) as cost of the proceedings.
Order shall be complied within one month from the date of receipt of order, failing which the complainant is entitled for 9% interest per annum for the whole amount from the date of order till realization.
Pronounced in the open court on this the 16th day of February, 2013.
Sd/-
Smt. Seena. H
President
Sd/-
Smt. Preetha.G.Nair
Member
Sd/-
Smt. Bhanumathi.A.K
Member
A P P E N D I X
Exhibits marked on the side of complainant
Ext. A1– Copy of the Health care Mebership Certificate dtd. 23/10/09.
Ext. A2- Copy of the discharge certificate of Westfort Hospital dtd. 21/03/10.
Ext. A3- Copy of the Medical certificate issue by the Westfort hospital .
Ext. A4- Copy of claim form.
Ext.A5- copy of the bills of Westfort hospital.
Ext. A6- Copy of the lawyer notice sent by the complainant to the oppsite party with postal receipt dtd. 20/04/2011.
Ext.A7- Acknowledgement card dtd.23/04/2011.
Exhibits marked on the side of opposite party
Ext. B1- Copy of the master policy agreement between opposite party no.2 and opposite party no.1 along with the schedule attached to the policy dtd. 10/12/2009.
Ext. B2- Copy of the Tympanometry test report of the complainant by Ephphatha Speech & Hearing Centre dtd. 21/02/2007.
Ext. B3- Claim forms received from 01/04/2010 to 30/04/2010.
Witness examined on the side of complainant
Nil
Witness examined on the side of opposite party
Nil
Cost allowed
Rs. 1000/- (One Thousand only )allowed as cost of the proceedings.
