CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM.

Present

Sri. Santhosh Kesavanath P. President

Smt. Bindhu M. Thomas, Member

                                             Sri. K.N. Radhakrishnan, Member

 

CC No 259/10

 

Saturday the 25^th day of June, 2011

 

Petitioner                                              : Asok.K,

                                                             Kuruvachra House,

                                                             Gandhinagar PO,

                                                               Kottayam.

                                                               Mohan Mammen)

                                                        Vs.

Opposite party                                     :   The Divisional Manager,

                                                                Oriential Insurance Co.Ltd.,

                                                                 Divisional Office NO1,

                                                                 PB No.166, 3^rd Floor,

                                                                 Mattethra Buildings, M.C. Road,

                                                                 Baker Jn, Kottayam.

                                                                 (Sajan A Varghese)

 

 

 

            The complainant’s case is as follows.

 

            In the year 2005-2006 the opposite party company made advertisements through various medias and Pamphlets stating that their medi claim policy will cover the expenses incurred for the Allopathy, Ayurvedha, Homeo and Unani treatment for the policy holders. Attracted by the terms offered for the said mediclaim policy the complainant had taken a mediclaim policy for himself and his family in the year 2005-2006 and the said policy was renewed periodically. On 11/2/2006, complainant renewed the said policy for himself and his wife and his parents for a total amount of Rs. 2,25,000/- for his family. The wife of the complainant was suffering from Rheumatic Arthritis and she had under gone ayurvedic treatment at Kooplicat Ayurveda Hospital & Toxycure Centre Kottayam as an inpatient from 8/11/2006 to 25/11/2006. The complainant had incurred treatment expenses Rs. 43,301/-. The said hospital is an approved ayurvedic hospital of the opposite party insurance company. The complainant submitted a claim for Rs.43,031/- along with relevant bills and original policy document to the opposite party. The claim amount was so far not reimbursed by the opposite party inspite of repeated demands and requests by the petitioner. The complainant contacted the officials of the opposite party for getting reimbursement of the amount, but they always maintained their stand that medi claims are processed and settled by another agency at Chennai and the complainant believed the said version of the opposite party. Finally on 20/8/10 the complainant met the opposite party personally and enquired about this claim. Then the opposite party stated that they have repudiated the claim. But no letter or other communication given to the complainant regarding the repudiation of the claim till 20/9/2010. The acts of the opposite party amounts to deficiency in service and unfair trade practice. The complainant alleged that he has suffered much loss and mental agony due to the aforesaid acts of the opposite party. Hence the complainant filed this complaint claiming Rs. 82,357 with 18% interest per annum as the claim amount along with costs.

            Notice was served to the opposite party. But the opposite party failed to file the version even after several postings. Hence the opposite part was set expartee.

Points for consideration are:

i)                    Whether there is any deficiency in service or unfair trade practice on the part of the opposite party?

ii)                   Reliefs and costs?

Evidence consists of affidavit filed by the complainant and Exts. A1 to A9.

            Heard the counsel for the complainant and perused the documents placed on record by the complainant. The complainant averred that he took the mediclaim policy attracted by the terms offered for the said mediclaim policy. Copy of the prospectus for the medicalim policy is produced and marked as Ext.A1. According to the complainant in the year 2005-2006, when he took the mediclaim policy the said policy covered the expenses incurred for Allopathy, Ayurvedha, Homeo and Unani treatment for the policy holders. The complainant further averred that his wife took Ayurvedic treatment at Kooplicat Hospital and incurred treatment expenses of Rs.43,031/- Evidencing the said expenses he produced photocopies of medical bills issued from Kooplicat Ayurveda Hospital and they are marked as Ext.A4 series. The complainant next averred that the claim submitted by him was not repudiated till 20/9/2010. The complainant alleged that the acts of the opposite party in not responding to the claim submitted by the complainant is a clear case of unfair trade practice and deficiency in service. As the opposite party chose not to contest, the allegations and averments of the complainant against the opposite party remain unchallenged. As per IRDA regulations, on receipt of the claim form, the insurer shall within a period of 30 days, either settle the claim or repudiate the claim. In this case the opposite party has failed to act as per the regulations of IRDA.   From the evidence placed on record we feel that the acts of opposite party amounts to unfair trade practice and deficiency in service. In our view the opposite party is liable to compensate the loss suffered by the complainant. Point no.1 is found accordingly.

            In view of the findings in point no.1 the complaint is allowed.

            The opposite party will process the claim submitted by the complainant within one month of receipt of the order failing which the opposite party will pay the claim amount Rs.43,031/- with interest @ 9% per annum to the complainant. The opposite party is ordered to pay Rs.3000/- as compensation for the delay caused by them in processing the claim along with litigation cost of Rs.2000/- to the complainant.

            This order will be complied with within one month of receipt of the order.

 

Dictated by me transcribed by the Confidential Assistant corrected by me and pronounced in the Open Forum on this the 25^th day of June, 2011.

 

Smt. Bindhu M. Thomas, Member                    Sd/-    

                       

Sri. Santhosh Kesavanath P. President Sd/-    

           

Sri. K.N. Radhakrishnan, Member                    Sd/-                                        

 

Ext.A1-Photocopy of the prospectus

Ext.A2-photocopy of the policy document dtd 11/2/05

Ext.A3-Photocopy of the discharge summary issued by Kooplicate Hospital

Ext.A4 series-Photocopy of medical bills issued from Kooplicate Ayurveda Hospital

Ext.a5-Photocopy of policy document dtd 15/2/10 numbered as 441300/48/2010/3057

Ext.A6-Photocopy of policy document dtd 14/2/06 numbered as 441300

Ext.A7-Photocopy of policy documents dtd 14/2/07

Ext.A8-Photocopy of policy document dtd 14/2/08

Ext.A9-Photocopy of policy document dtd 14/2/09

Nil

 

By Order,

 

 

Senior Superintendent.