By. Sri. K. Gheevarghese, President:
The complaint filed against the opposite parties for the repudiation of the insurance claim.
2. The complaint in brief is as follows: The complainant is a policy holder along with the family members issued by the 1st opposite party. The complainant took the policy in the year 2009 and renewed the policy from time to time. The policy of the complainant is having valid from 24.03.2011 to 23.03.2012.
3. The complainant availed medical treatment as in patient from Vimala Mary Ayurveda Mission Hospital Pulpally due to joint pain. The expenses for the treatment in total was met by the complainant and it was Rs.6,540/-. After discharge from the hospital, the complainant moved a claim before the 1st opposite party through 2nd opposite party. The claim of the complainant was not considered by the opposite party and more over it was later rejected. The insured complainant is still undergoing treatments for the ailment. The irresponsible attitude of the opposite parties is a deficiency in service. There may be an order directing the opposite parties to pay the complainant Rs.6,540/- the expenditure incurred for the treatment along with cost and compensation of Rs.10,000/-. The complainant is also entitled to get interest at the rate of 12% from the date of hospitalization till the payment of the same.
4. The 1st opposite party filed version. The complainant along with the family members are insured for the period starting from 24.03.2011 to 23.03.2012. The terms and conditions of the policy is such that if the insured admitted and treated in government hospital or medical college for ayurvedic treatments it can be considered. Whereas the complainant in this case had undergone treatments in private ayurvedic hospital and for this reason the claim of the complainant could not be responded positively.
5. The complainant's claim of Rs.800/- towards the room rent for medical expenses Rs.940/- and the treatment expenditure Rs.4,200/- along with transportation expense of Rs.600/- are not entitled to be given by this opposite party.
6. The claim of the complainant was proved by the 2nd opposite party and the reason for rejection of the claim was also intimated to the complainant on 20.08.2011. If any grievances is there the complainant would have appealed against the decision through TPA. The complaint is not maintainable it is to be dismissed with cost.
7. The 2nd opposite party is set exparte.
8. The Points that are to be decided:-
1. Is there any deficiency in service on the part of the opposite parties in the rejection of the claim?
2. Relief and Cost.
9. Points No.1 and 2:- The evidence in this case consist of the proof affidavit of the complainant and 1st opposite party. Exts.A1 to A12 and B1 are the documents marked. The
oral testimony of the complainant is also brought out in this case.
10. The case of the complainant is that the medical expenditure incurred for the treatment of the complainant as an inpatient in Vimala Mary Ayurveda Mission Hospital is not sanctioned. Ext.A3 is the copy of the discharge summary of Vimala Mary Ayurveda Mission Hospital, Pulpally. The date of admission of the complainant in hospital was on 22.06.2011 and discharged on 30.06.2011. The complainant availed treatment as inpatient from the Vimala Mary Ayurveda Mission Hospital. The complainant forwarded claim form to the 1st opposite party insurer through 2nd opposite party the TPA and it is marked as Ext.A2. The complainant had also undergone treatment from the Doctor who is in government service. The 2nd opposite party is the 3rd party agent processing the claim,who is set exparte.
11. The complainant was examined as PW1 and he deposed that the treatment availed by the complainant is from a 60 bedded hospital. Ext.B1 is the policy and the same is also produced by the complainant as Ext.A1.
12. The reason for the repudiation of the claim according to the 1st opposite party is that the insured had not undergone treatment as averred in the policy terms and conditions. The policy hold by the complainant is a Family Medicare. It is true that the claim forwarded by the insured is truly under directions of the terms and conditions of the policy. The exclusion clauses in the policy has not detailed reasons for the rejection of the policy of the complainant. The complainant had undergone ayurvedic treatments in private hospital as an inpatient. The claim of the complainant was forwarded to the 1st opposite party through the 3rd party agent who is set exparte in this case.
13. The complainant had undergone as inpatient for treatments as such Kizhi for which Rs.4,200/- was paid, for rent and medicinal charges RS.1,740/- was spent as per Ext.A4. The exclusion Clause 4.10 details that the preliminary expenditure of diagnosis of ailment which excluded from the claim. The documents produced by the complainant on verification confirm the expense of Rs.5,940/- for the treatments. The repudiation of the claim of the complainant for the treatment as inpatient in Vimala Mary Ayurveda Mission Hospital, Pulpally is a deficiency in service and the complainant is to be given the expenditure for treatments along with cost. The 2nd opposite party is only a processing agent of the insurer. The liability of the insured sum is confined to the 1st opposite party.
In the result the complaint is partly allowed. The 1st opposite party is directed to pay Rs.5,940/- ( Rupees Five Thousand Nine Hundred and Forty Only) the amount spent as per records for the treatments availed along with cost of Rs.500/- ( Rupees Five Hundred Only) to the complainant. This Order is to be complied within one month from the date of receipt of this.
Pronounced in Open Forum on this the day of 30th March 2012.
Date of Filing:18.11.2011.
