BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI

Dated this the 30th day of July, 2009

Present:

SRI.LAIJU RAMAKRISHNAN PRESIDENT

SMT.SHEELA JACOB MEMBER

SMT.BINDU SOMAN MEMBER

C.C No.202/2008

Between

Complainant : Jiji Mathew,

Kanjirathumkunnel House,

Ellakkal,

Chithirapuram.

(By Adv: Pratheesh Prabha)

And

Opposite Parties : 1. The Manager,

United India Insurance Company Ltd.,

Adimaly Branch,

Kannattu Shopping Complex,

Adimaly P.O,

Adimaly-685561.

(By Adv: Lakshmanan T.J)

2. The Manager,

TTK Health Care,

TPA Private Limited,

1400-B Mareena Building,

M.G Road, Ravipuram,

Ernakulam,

Kochi – 682016.

O R D E R

SMT.SHEELA JACOB(MEMBER)

The complainant availed a mediclaim policy from the 1st opposite party. The 2nd opposite party is an agency engaged by the 1st opposite party to deal with mediclaim policy transaction. The policy was taken by the complainant on 14.12.2007. The policy covered with the period from 14.12.2007 to 13.12.2008 and premium is Rs.1,549/-. The policy No. is 101104/48/07/97/00003135. As per the policy terms, the complainant is entitled for treatment expenses. On 28.01.2008, the complainant was admitted in the Lourdes Hospital, Ernakulam. He had undergone treatment as inpatient. The complainant had spend Rs.11,481/- for treatment in connection with his illness. Though a claim was made to the opposite party, the matter was being postponed with a view to harass the complainant calling up on him to produce certain certificate which is not in his possession. The claim was repudiated on unreasonable grounds. Alleging that the repudiation is illegal and amounts to deficiency in service, the complaint has been filed for a direction to pay the hospital charges and also compensation for deficiency in service.

2. The opposite party filed written version admitting the insurance policy. It is contended that the complainant was not submitted any of the claim papers with the 1st opposite party. The complainant submitted the claim form before the 2nd opposite party, only after five months from the date of discharge. No sufficient explanation was given by the complainant about the delay. So clarifications were sought from the complainant as per letter which was not replied. The insurance company acted only in accordance with law. So far as the complainant did not submit the claim form in time. Therefore the claim was repudiated on legal grounds and there is no deficiency in service.

3. The point for consideration is whether there was any deficiency in service on the part of the opposite parties, and if so, for what relief the complainant is entitled to?

4. The evidence consists of the oral testimony of PW1 and Exts.P1 to P5 marked on the side of the complainant and the oral testimony of DW1 and Ext.R1 marked on the side of the opposite parties.

5. The POINT:- There is no dispute that the complainant is a person eligible for the mediclaim. It covers the period from 14.12.2007 to 13.12.2008. The claim relates to the inpatient treatment undergone by the complainant for the period from 28.01.2008 to 02.02.2008. The complainant was examined as PW1. Ext.P1 is the copy of the insurance certificate. Ext.P2 is the copy of the health card. Ext.P3 is the copy of the bills. The total amount of Ext.P3 bill is Rs.11,481/-. Ext.P4 is the copy of the repudiation letter. Ext.P5 is the copy of the medical certificate. In the cross examination PW1 has stated that he had submitted the claim form with in one week from the date of discharge. The opposite party as DW1 would state that the complainant has submitted the claim form in June, 2008. So the claim was repudiated on legal grounds. Ext.R1 is the specimen of the policy condition. The opposite party has repudiated the claim only for the reason that the complainant has submitted the claim form and other documents only after five months from the date of discharge. But in the cross-examination and perusing relevant documents, the opposite party could not prove that the complainant has submitted the claim form only after five months from the date of discharge. Therefore the rejection of the claim is not on unreasonable grounds and amounts to deficiency in service. So the opposite party is bound to pay eligible compensation for inpatient treatment of Rs.11,481/- evidenced by Ext.P3(series) bills with 12% interest from the date of this petition. In the circumstances of this case the complainant is entitled to the costs of this petition, which we would limit to Rs.1,500/-.

In the result, the petition allowed. The 1st opposite party is directed to pay to the complainant Rs.11,481/- (as per the Ext.P3 series bills) being the medical expenses with 12% interest from the date of filing the petition and Rs.1,500/- as costs of this petition within one month of receipt of a copy of this order, failing which the amount shall carry 12% interest from the date of default.

Pronounced in the Open Forum on this the 30th day of July, 2009.

Sd/-

SMT.SHEELA JACOB(MEMBER)

Sd/-

SRI.LAIJU RAMAKRISHNAN(PRESIDENT)

Sd/-

SMT.BINDU SOMAN(MEMBER)

APPENDIX

Depositions :

On the side of Complainant :

PW1 - Jiji Mathew

On the side of Opposite Party :

DW1 - Ninan Alex P

Exhibits:

On the side of Complainant:

Ext.P1 - Copy of Policy Insurance Certificate

Ext.P2 - Copy of Health Card

Ext.P3 series (15 Nos) - Copy of Medical Bills for Rs.11,481/-

Ext.P4 - Copy of Claim repudiation letter

Ext.P5 (2 Nos) - Copy of the Medical Certificate.

On the side of Opposite Party :

Ext.R1 - Specimen of the Policy Condition.