IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 29th day of October, 2012.
Present : Sri. Jacob Stephen (President)
Sri. N. Premkumar (Member)
Smt. K.P. Padmasree (Member)
C.C. No. 115/2012 (Filed on 28.06.2012)
Between:
Ajithkumar. R.,
Kanakkamannil House,
Velliyara P.O.,
Ayroor – 689 612. … Complainant.
And:
1. The Manager,
National Insurance Co. Ltd.,
Aluva Divisional Office,
Post Box No. 89,
Urumbath Building,
Pump Junction, Aluva,
Pin – 683 101.
2. The Branch Manager,
National Insurance Co. Ltd.,
Govt. Hospital Road,
Pathanamthitta. … Opposite parties.
(By Adv. P.P. Mohammed Mustapha)
ORDER
Sri. Jacob Stephen (President):
The complainant has filed this complaint against the opposite parties for getting a relief from the Forum.
2. The complainant’s case is that he is a medi-claim policy holder of the opposite parties under Sampoorna Arogya Bima Medi Claim policy for a sum of ` 50,000 which is valid from 01.04.2011 to 31.03.2012. While so, he had undergone treatment for certain ailments at Athura Hospital, Seethathodu and he had spent an amount of ` 9,905-68 for his treatment from 17.12.2011 to 28.12.2011. Thereafter, he had submitted his claim along with relevant documents. But there was no response from the side of the opposite parties and thereby he was denied his genuine claim by the opposite parties. Because of the above said acts of the opposite parties, the complainant had sustained mental agony and financial loss, which is a deficiency of service from the part of the opposite parties and the opposite parties are liable for the same to the complainant. Hence this complaint for the realization of a total amount of ` 20,000 under various heads including the claim amount and other cost etc.
3. Opposite parties entered appearance and filed their version with the following contentions: Opposite parties admitted the policy issued to the complainant and the complainant’s request for the claim. According to the opposite parties, the hospital where the complainant had undergone treatment cannot be treated as an hospital as per the terms and conditions of the policy. So they are not liable to honour the claim of the complainant for the above said reason and they justified their act of repudiation of the claim to the complainant. Therefore, they contended that they have not committed any deficiency in service and hence the complainant is not entitled to get any of the reliefs prayed for in the complaint. With the above contentions, opposite parties prays for the dismissal of the complaint.
4. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?
5. The evidence of this complaint consists of the complaint filed by the complainant and Exts. A1 to A4 and Ext. B1. After closure of evidence, both sides were heard.
6. The Point: The complainant’s allegation is that though the complainant is a valid policy holder of the opposite parties’medi-claim policy under Sampoorna Arogya Bima Medi Claim policy, opposite parties denied his claim for ` 9,905-68 spent by the complainant for his treatment at Athura Hospital, Seethathodu during the policy period. According to the complainant, the above said acts of the opposite parties is a clear deficiency in service and the opposite parties are liable to the complainant for the same.
7. In order to prove the case of the complainant, 4 documents produced by the complainant were marked as Exts. A1 to A4 on the basis of the complaint filed by the complainant. Ext. A1 is the medical certificate of the complainant issued by the treated doctor in the prescribed form of the opposite parties. Ext. A2 is the copy of the policy certificate in question. Ext. A3 is the cash bill dated 27.12.2011 for ` 9,905-68 issued from Athura Hospital, Seethathodu. Ext. A4 is the copy of the certificate issued from Athura Hospital, Seethathodu stating the facilities available at that hospital.
8. At the same time, the contention of the opposite parties is that the hospital from where the complainant obtained treatment cannot be treated as an hospital as per the terms and conditions of the policy in question and hence they are not liable to honour the claim of the complainant and hence they argued that they have not committed any deficiency of service to the complainant and the complainant is not entitled to get any of the reliefs as prayed for in the complaint.
9. In order to prove the contentions of the opposite parties, they have submitted the copy of the master policy agreement and it was marked as Ext. B1.
10. On the basis of the contentions and arguments of the parties, we have perused the entire materials on record and found that there is no dispute between the parties that the complainant is a valid policy holder of the opposite parties and the complainant had undergone treatment at Athura Hospital, Seethathodu from 17.12.2011 to 28.12.2011 and the complainant had spent an amount of ` 9,905-68 for the said treatment. The only dispute is with regard to the standard of the hospital. According to the complainant, the hospital where he had undergone treatment will come within the purview of the policy conditions. But according to the opposite parties, the said hospital cannot be treated as an hospital under clause 3(2) to 3(5) of the policy issued by the opposite parties. But on a perusal of Exts. A1 to A4, the treatment of the complainant and the hospital where the complainant had obtained the treatment will come under the purview of clause 3(2) to 3(5) of Ext. B1, as the facilities shown in Ext. A4 are in accordance with the specification shown in clause 3(2) to 3(5) of Ext. B1. Moreover, the opposite parties have not adduced any evidence to discard Exts. A1, A3 and A4. In the circumstances, the denial of the complainant’s claim by the opposite parties is a clear deficiency in service and hence this complaint is allowable.
11. In the result, this complaint is allowed, thereby the opposite parties are directed to pay the claim amount of ` 9,905-68 (Rupees Nine thousand nine hundred and five and sixty eight paise only) along with compensation of ` 1,000 (Rupees One thousand only) and cost of ` 500 (Rupees Five hundred only) to the complainant within 15 days from the date of receipt of this order, failing which the complainant is allowed to realize the whole amount with 10% interest per annum from today till the realization of the whole amount.
Dictated to the Confidential Assistant, transcribed and typed by him, corrected by me and pronounced in the Open Forum on this the 29th day of October, 2012.
(Sd/-)
Jacob Stephen,
(President)
Sri. N. Premkumar (Member) : (Sd/-)
Smt. K.P. Padmasree (Member) : (Sd/-)
Appendix:
Witness examined on the side of the complainant: Nil.
Exhibits marked on the side of the complainant:
A1 : Medical certificate (attending doctor’s report) of the
complainant issued by the opposite parties.
A2 : Copy of the policy certificate.
A3 : Cash bill dated 27.12.2011 for ` 9,905-68 issued from
Athura Hospital, Seethathodu.
A4 : Copy of the certificate issued from Athura Hospital,
Seethathodu.
Witness examined on the side of the opposite parties: Nil.
Exhibits marked on the side of the opposite parties:
B1 : Copy of Master Policy Agreement.
(By Order)
(Sd/-)
Senior Superintendent.
Copy to:- (1) Ajithkumar. R., Kanakkamannil House,
Velliyara P.O., Ayroor – 689 612. (2) The Manager, National Insurance Co. Ltd.,
Aluva Divisional Office, Post Box No. 89,
Urumbath Building, Pump Junction, Aluva,
Pin – 683 101.
(3) The Branch Manager, National Insurance Co. Ltd.,
Govt. Hospital Road, Pathanamthitta.
(4) The Stock File.
