cccccPBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 31st day of October 2012
Filed on : 07/12/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member
C.C. No. 678/2011
Between
Paul Mendez, : Complainant
Vallayara, Mannuchira, (By Adv. Afsal Khan, Kalppaa Files
Paravoor P.O., Perumpadanna, 3rd floor, Velleparambil building,
Ernakulam. Kaloor, Cochin-17)
And
1. The Divisional Manager, : Opposite parties
New India Assurance Co. Ltd., (1st O.P. by Adv. P.G. Ganappan
Ernakulam. Anjali, Thrikkakara P.O.,
2. The Senior Branch Manager, Erakulam, Kochi-21)
TTK Health Care TPA Pvt. Ltd.,
39/4130, 1st floor, Mareena
Building, M.G. Road, (Opposite parties 2 & 3
Ernakulam, Kochin-16. absent)
3. The Executive Director,
Welfare Service Ernakulam,
Ponnurunni, Vyttila P.O,
Kochin-19.
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
On 07-01-2011 the complainant and his family insured under a group insurance scheme initiated by the Ernakulam Angamaly Arch Dioces and the 1st opposite party. The complainant joined the scheme on the basis of a notification published by the 3rd opposite party stating that the policy covers existing ailments and there was no need for a medical check up. The complainant was admitted in Lourde’s hospital, Ernakulam on 18-03-2011 due to chest pain and was subjected to heart surgery on 22-03-2011. Due to the deficiency in service on the part of the 1st and 2nd opposite parties the complainant could not get the benefits of cashless treatment. The 2nd opposite party caused a letter dated 29-03-2011 to the Hospital stating that the claim was rejected. The complainant had to incur a sum of Rs. 1,44,662.27 towards treatment expenses. After discharge from the hospital the complainant approached the opposite parties for reimbursement of the amount, but in vain. Apart from the insurance amount the complainant is entitled to get a compensation of Rs. 2 lakhs and Rs. 20,000/- towards traveling expenses. This complaint hence.
2. The version of the 1st opposite party
The sum insured under the policy is Rs. 1,00,000/-. The claim of the complainant was settled by the 2nd opposite party by paying Rs. One lakh by cheque No. 10631 dated 27-12-2011 of the Axis Bank, Ernakulam in favour of the 3rd opposite party. The 3rd opposite party is the concerned authority to issue the cheque in favour of the complainant.
3. The opposite parties 2 and 3 turned a deaf ear to the notice issued to them from this Forum. The complainant was examined as PW1 and Exts. A1 to A7 were marked. Heard the learned counsel for the contesting parties.
4. The only point that came up for consideration is whether the complainant is entitled to get a total amount of Rs. 3.64,662.27 from the opposite parties.
5. The following issues are undisputed
a. The complainant and his family availed mediclaim policy of
the 1st opposite party under the auspice of the 3rd opposite
party with sum insured of Rs. One lakh with effect from
07-01-2011.
b. During the currency of the policy the complainant underwent
treatment at Lourdes Hospital, Ernakulam for heart ailment
from 18-03-2011 to 01-04-2011 evident from Ext. A3
discharge summary.
c. The 2nd opposite party rejected the insurance claim of the
complainant by Ext. A5 letter stating that “CAG done and
surgery advised dated 02/12/2010. Planned surgeries before
the inception of the policy not payable cashless not available
Previous AL for Rs. 10,000/- stands null and void”.
d. During the proceedings the 3rd opposite party paid a sum of
Rs. 99,000/- to the complainant towards insurance claim.
6. According to the 1st opposite party they have forwarded ;;a cheque to the tune of Rs. One lakh in favour of the 3rd opposite party to disburse the same to the complainant. However the 3rd opposite party paid only Rs. 99,000/- to the complainant on 17-02-2012. The 1st opposite party maintains that the complainant is entitled to get the balance amount of Rs. 1,000/- from the 3rd opposite party.
7. At the out set the 2nd opposite party repudiated the claim of the complainant to avail the cashless facility on irregular grounds however they realized their mistake and recommended for the payment of the insurance claim subsequently. By the time the complainant had to arrange the hospital expenses on his own. The denial of cashless facility to the complainant amounts to deficiency in service on the part of the 2nd opposite party, to which they have already answered by allowing the insurance claim why the further amount of Rs. 1,000/-was not paid to the complainant by the 3rd opposite party has not been explained for whatsoever reasons which alone is the contention of the complainant. No reasonable explanation having been offered for withholding the balance amount of Rs. 1,000/-can not legally be upheld for which the 3rd opposite party is answerable but for which no explanation is forthcoming. This amounts to deficiency of service to put the rest in the least to pay the amount with interest which are feel would the question of law in issue which would necessarily not call for compensation and costs of the proceedings. Ordered accordingly.
8. In the result, we partly allow the complaint and direct the 3rd opposite party shall pay the balance insurance amount of Rs. 1,000/- to the complainant with 12% interest p.a. from 17-02-2012 till payment.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of the order.
Pronounced in the open Forum on this the 31st day of October 2012
