DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD

Dated this the 16^th day of February 2011

Present : Smt.Seena H, President

: Smt. Preetha.G. Nair, Member

: Smt. Bhanumathi.A.K, Member Date of filing: 31/12/2009

(C.C.No. 1/2010)

Sreejith.K

S/o.Venugopal

17/310, “Sreesankara”

Manappullikavu,

Kunnathurmedu Post

Palakkad - 13 - Complainant

(By Adv.C.Sreekumar)

V/s

1.The Manager

Bajaj Allianz Life Insurance Co.Ltd

No.1078, 2^nd Floor,

United Chambers, Sathi Road

Ganapathy, Coimbatore

Tamilnadu – 641 006.

(By Adv.K.S.Menon & A Santhoshkumar)

2.The Manager

Bajaj Allianz Life Insurance Co.Ltd

1^st Floor, Jamshi Plaza,

East Fort Road, Fort Maidan,

Palakkad – 678 001.

(By Adv.K.S.Menon & A Santhoshkumar)

3. Dr.C.Palanivelu,

Director

GEM Hospital & Research Centre (P) Ltd

45-A, Pankaja Mill Road,

Ramanathapuram, Coimbatore – 641 045. - Opposite parties

O R D E R

By Smt.SEENA H, PRESIDENT

The case of the complainant in brief:

Complainant availed a health plan policy from the opposite party on 20/3/2009. His parents were also included in the policy benefits as dependent members and they are entitled to the policy benefits. The amount covered by the policy is Rs.2 lakhs. Opposite party is having tie up with most of the hospitals including GEM hospital, Coimbatore. As per the policy complainant and his dependents can enjoy the benefit and cashless facilities for medical treatment and hospitalization. Complainant's father approached GEM Hospital, Coimbatore for check up and treatment for stomach ache as the Gastero Enterology department of the hospital is the one and best one. Before going to the said hospital, complainant's father enquired with the 2^nd opposite party and the 2^nd opposite party assured that treatment will be provided by the hospital. 2^nd opposite party also reminded of the ID card and photograph to be taken with him. But the hospital authorities expressed their inability to provide cashless medical treatment. The hospital authorities also stated that they have no tie up with Bajaj Allianz. Thereafter complainant approached MIMS Hospital, Coimbatore on 17/6/2009 and also on 3/7/2009 for treatment. Complainant has to incur Rs.5049/for his father’s treatment. Complainant issued a lawyer notice dated 14/9/2009 informing the insufficiency of service on the part of opposite parties and demanding the premium amount paid along with interest and compensation. Opposite parties neither replied nor paid the amount. Hence the complaint.

Opposite party No.3 was set exparte. Opposite parties 1 & 2 filed version contending the following.

Policy is admitted by the opposite parties 1 & 2. According to Opposite parties they are having tie up with the hospitals mentioned in the brochure including GEM Hospital Coimbatore. According to opposite parties, the father of the complainant has gone to GEM Hospital only for consultation and not for any treatment. As per the terms of the policy hospitalization and treatment alone are cashless and consultation is outside such terms. Further opposite party is not aware of the expenses incurred for consultation with any other doctor and opposite parties is not bound to compensate the complainant with any such amount. Complainant is not entitled to get refund of the premium or any other amount as prayed for. Further investigation by opposite party revealed that the complainant's father has approached GEM Hospital only for the purpose of consultation which as per the terms of the policy is not covered. Hence opposite party 1 & 2 prays for dismissal of the complaint along with cost.

The evidence adduced by the parties consists of their respective affidavits. Ext.A1 to A.4 marked on the side of the complainant. Ext.B1 to B.2 marked on the side of opposite party 2.

Now the issues that arise for our consideration are

1. Whether there is any deficiency in service on the part of opposite parties ?

2. If so, what is the relief and costs complainant is entitled to ?

Issue 1 & 2

It is the case of the complainant that his father being a beneficiary under a health plan policy approached GEM Hospital, Coimbatore for treatment as the name of the said hospital was included in the brochure provided by opposite party 1 & 2 for seeking cashless medical treatment as per the terms of the policy. The hospital authorities expressed their inability to provide cashless treatment as they have no tie up with the opposite party 1 & 2.

Opposite party 1 & 2 on the other hand contented that complainant’s father had gone to GEM Hospital only for consultation and not for any treatment. As per the terms of the policy, hospitalization and treatment alone are cashless and consultation is outside such terms. It is also denied by opposite party 1&2 that GEM Hospital has told the complainant that they had no tie up with the opposite party 1 & 2.

It is not in dispute that complainant's father is a beneficiary under the Health Insurance Plan. Complainant's father has gone to GEM Hospital and no further treatment was taken from the said hospital is proved by Ext.B1. It is not in dispute that the complainant’s father has not done any check up from the said hospital. Without any check up, the Director of the GEM Hospital has given a certificate stating the complainant has approached them for investigation only. A common man always approach a doctor for consultation, it is the expert doctor who in turn advice hospitalization if necessary. So we find that Ext.B1 is not at all a reliable evidence. Moreover opposite party has not examined the signatory of the said document also.

It is true that as per the policy conditions only hospitalization charges can be claimed. But the case of the complainant is that the hospital has denied any tie up with opposite party 1 & 2. Though the GEM Hospital was made a party, they were set exparte. Opposite party 1 & 2 has not taken any steps to examine the hospital authorities with whom they have tie up, which would have definitely thrown light on to what has been transpired between the complainant’s father and the hospital authorities.

In view of the above stated facts and circumstances of the case, we are of the view that there is deficiency in service on the part of opposite parties 1 & 2. In the result complaint allowed.

Opposite parties 1 & 2 jointly and severally directed to pay complainant an amount of Rs.5,000/- as compensation for deficiency in service on their part along with Rs. 1000/ as cost of the proceedings. Order to be complied within one month from the date of receipt of order failing which the whole amount shall carry interest at the rate of 9% per annum from the date or order till realization.

Pronounced in the open court on the 16^th day of February 2011.

Sd/- Smt.Seena. H

President

Sd/-

Smt.Preetha.G.Nair

Member

Sd/-

Smt.Bhanumathi.A.K

Member

APPENDIX

Exhibits marked on the side of the complainant

Ext.A1 – Insurance Policy dated 20/3/2009

Ext.A2 – ID Card of the complainant's family

Ext.A3 series – Medical bills

Ext.A4 – Copy of lawyer notice, postal receipt and postal A/D card

Witness examined on the side of the complainant

PW1 – Sreejith K

PW2 – Venugopalan V

Exhibits marked on the side of the opposite party

Ext.B1 – Attendence certificate issued by GEM Hospital to Sreejith

Ext.B2 – TPA Guide Book issued by Bajaj Allianz

Witness examined on the side of the Opposite party

Nil

Cost Allowed

Rs.1,000/ allowed as cost of proceedings.