SMT.MOLYKUTTY MATHEW : MEMBER

        This is a complaint filed by the complainant U/S 12 of the Consumer Protection Act 1986  for an order directing  the OPs to pay an amount of  Rs.43,750/- to the complainant with 12% interest from 8/3/2017 till realization  and  Rs.1,00,000/- as compensation   for  mental agony and cost  of the complainant for the deficiency of service on  their  part.

The brief  of the complaint:

    The  complainant  was working  in LIC of India as Development officer and that he had retired from service on 30/4/2015.  There is a master policy issued by the 1^st OP which all employees of LIC was insured.  So the complainant was one of the insured under the policy.  After retirement the complainant  was  directly paying premium for the medical claim to the company for Rs.957/- per month.  The complainant had availed treatment from Narayanalayam, Ayurveda Chikilsakendram and Research Centre Thiruvengapuram ,Pattambi for his facial palsy and other bodily problems,  He was treated by Dr.N.N.Devan  Namboodiri  who is a competent medical officer.  Thereafter the  complainant had handed over treatment particulars to LIC to get claim from the  OP for Rs.43,750/-.But instead of the 1^st OP directly entering the  application of claim from the insured for settlement, the 1^st OP had engaged the 2^nd OP to entertain  claims and only if vidal, the 2^nd OP recommends 1^st OP settled it, the insured get their dues.  The complainant’s claim was not recommended by 2^nd OP and  it was repudiated which was informed to 1^st OP and the 1^st OP informed the complainant that his claim was repudiated.  The reason for repudiation is that hospital from which the complainant had availed treatment  was not having 15 beds instead there are only 13 beds and such  a hospital does not  come under the definition  hospital in their policy.  But in clause 13(a) of the  master policy which shows that a hospital should have at least 10 IP beds , where population of the place is less than 10 lakhs.  By the  rejection of the policy the OP mislead  the complainant and committed suppression of material facts.  On 9/8/2017 the complainant sent a registered lawyer notice to 1^st OP’s head office.  But the OP’s not sent a reply or settled the claim also. The act of  OP’s  the complainant caused much mental agony and financial loss.  So there is deficiency of service and unfair trade practice on the part of OP’s.  Hence the complaint.

       After receiving notice 1^st  OP entered before the commission  and filed his written version contending  that the complainant has  violated the conditions in the insurance policy.  The complainant might have ignored the conditions as enumerated in the policy document.  The complainant has by way of relief sought  compensation without in  any manner demonstrating that any loss in fact has been occasioned and in what manner computation of compensation claimed  has been made.  The complainant has miserably failed to produce the policy document in corroboration of his claim.  The complainant  is thus a motivated attempt to obtain  unfair advantage and the 1^st OP has no deficiency in service and unfair trade practice. Hence the complaint is liable to be dismissed.

      On the basis  of the rival contentions by the pleadings the  following  issues  were framed for consideration.

1. Whether there is  any deficiency of service   on the part of the opposite parties?
2. Whether the complainant is entitled for any relief?
3. Relief and cost.

     The evidence consists of the oral testimony of PW1 and  Exts. A1 to A9 were marked . On OP’s side DW1 was examined and Ext.B1 marked.

Issue No.1: 

                The  Complainant  adduced evidence before the commission by submitting  his chief affidavit in lieu of  his chief examination to the tune of the pleadings in the complaint and denying the  contentions in the version.  He was cross examined as PW1 by the OP.  The documents  Exts.A1 to A9 were marked on his  part to substantiate his evidence. In Exts.A1&A2 are the cash receipts.  Ext.A3 is the discharge summary, Ext.A4 is the repudiation  letter issued by 2^nd OP, Ext.A5 is the rejection letter issued by 1^st OP, Ext.A6 is the copy of insurance policy,   Ext.A7 lawyer notice, Ext.A8 postal receipt and Ext.A9 is the copy of census conducted by the government.   According to the complainant, he is the  policy holder of  1^st OP and he promised that the OP is providing medical claim also.  But the 1^st OP rejected the claim instead of 1^st OP directly entertaining application of claim from the insured for settlement, the 1^st OP had engaged  2^nd OP to entertain  the claim and only if  2^nd OP recommended the 1^st OP settled it, the insured get their dues.  The complainant’s claim was not recommended by 2^nd OP and it was repudiated which was informed to the 1^st OP and 1^st OP informed the complainant that his claim was repudiated.  The reason for repudiation is  that hospital from which the complainant had availed treatment was not having 15 beds, instead  there are only 13 beds and that such a hospital does’nt come under the definition  hospital in their policy.  The DW1  also deposed before the commission that “ Dr.N.N. Devan Namboodiri  ഒരു  qualified  Ayurveda doctor ആണോ   എന്ന് അന്വേഷിച്ചിരുന്നോ?  TPA (2^nd OP) അന്വേഷിച്ചു കാണും.Facial palsy  എന്ന അസുഖവും , കൈവിരലുകളിൽ ചൊറിച്ചിലുള്ള കാര്യവും മനസ്സിലാക്കിയിരുന്നു.Ext.A3 നോക്കിയാൽ ചികിത്സയ്ക്കുശേഷം കൈയുടെ ചൊറിച്ചിലും വേദനയും കുറഞ്ഞതായി രേഖപ്പെടുത്തിയതായി  കാണാം? ശരിയാണ്.  വലതുവശത്തെ മുഖം കോടിപ്പോയതും കുറഞ്ഞതായി രേഖപ്പെടുത്തിയിട്ടുണ്ട്. Policy condition പ്രകാരം hospital  എന്ന definition ൽ പെടുന്നില്ല എന്നാണ് ഒരു കാരണം. Moreover the DW1 admits that Ext.B1 policy condition 3-18 ൽ  ജനസംഖ്യ 10 ലക്ഷത്തിൽ താഴെയുള്ള town ആണെങ്കിൽ hospital ൽ 10 impatient bed മതി എന്ന  condition ഉണ്ട്? ശരിയാണ്.3-5 എന്ന ആയുഷ് hospital ന്ർറെ definition  കൂടി ബാധകമാണ്. നാരായണാലയം എന്ന ഹോസാപിറ്റൽ സ്ഥിതി ചെയ്യുന്നത് പാലക്കാട് ജില്ലയിൽ  തിരുവെങ്ങാപ്പുറം എന്ന സ്ഥലത്താണ്. ഒറ്റപ്പാലംഎന്നതാലൂക്കിൽ സ്ഥിതി ചെയ്യുന്ന ഗ്രാമപഞ്ചായത്തിലാ ണ്തിരുവെങ്ങാപ്പുറം. Ext.A9 also admitted by DW1. Ext.B1 പ്രകാരം (3-9) 24 മണിക്കൂർ inpatient ആയി കിടന്നാൽ  മതി എന്നു പറഞ്ഞിട്ടുണ്ട്? ശരിയാണ്. OP.NO.1 സ്വതന്ത്രമായി അന്വേഷണം  നടത്തിയിട്ടില്ല . As per Ext.A9 census report , the total population of Thiruvengappuram village during the year 2011 is 33,942 and  during  2022-2023 is between  38,015-41409.  The number  of males and females are also seen in Ext.A9.  As per Ext.A6 and Ext.B1 when the population  is less than 10 lakhs needs  only  at least 10 inpatient beds in an admitted hospital.  The hospital in which  the complainant was admitted is having 13 beds.  So it is clear that no violation of policy condition from the side of complainant.  Since the OP is denied the medical  expenses. So there is deficiency of service on their part .  The 1^st OP vehemently stated that  there is no deficiency of service on their part.  They relied upon Ext.B1 to substantiate their defence.  As per item D4 excluding  centres for spas, massage and health rejuvenation procedure .  But  in this  case the complainant is suffering from facial palsy and itching  between fingers. 

    On  perusal of the pleadings, documents and evidence  we the commission held that the complainant is the policy holder of the insurance scheme and the policy coverage is also from 1/4/2016 to  31/3/2017.  The complainant was admitted in 28/3/2017 within the coverage period also.

  The OP produced some Hon’ble Supreme Court decisions in Ghaziabad Development Authority vs. Union of India 2006SCC 113, Bihar State Housing Board vs. Prio Ranjan Roy 1997 6 SCC487.  The National Commission in its judgment dated  3/5/2016 in FA 46 of 2010 between Mukul Diesel vs. The New India Assurance Co.Ltd held  para 16 in this situation, we hold the view that the policy should be interpreted strictly in its terms mentioned in the policy.  As per Ext.A6 in page 20-21 in clause 13 hospital is defined.  As per clause 13(a)  a hospital has at least 10 inpatient beds in those towns having a population of less than 10,00,000 and at least 15 inpatient beds in all other places.  In Ext.B1 policy also as per clause 3-18 suggest the same criteria.

   So we are of the considered view that the OPs are jointly and severally liable to pay the medical bill of Rs.43,750/- to the complainant.  But the OP’s failed to do so. So we hold that there is deficiency of service and unfair trade practice on the part of both OP’s.  Hence the issue No.1 found in favour of the complainant and  answered accordingly.

Issue Nos.2&3:

        As discussed above the complainant is the policy holder of 1^st OP.  The complainant undergone medical treatment on 28/3/2017 at Narayanalayam,Thiruvengappuram  and  he incurred  Rs.43,750/- within the policy coverage period.  So we hold  that the opposite parties are directly bound to redressal  the grievance caused to the complainant. So the complainant is entitled to get the medical expenses as described in Exts.A1&A2 from the OP’s.   Therefore we hold that the 1^st opposite party is liable to pay the medical bill for an amount of Rs.43,750/-  to the complainant and opposite parties 1&2 jointly and severally liable to pay an amount of Rs.10,000/- as compensation for mental agony of the complainant and Rs.4000/- as litigation cost. Thus the issue No.2&3 are also accordingly answered. 

          In the result the complaint is allowed in part  directing the 1^st opposite party  to pay the medical bill for an amount of Rs.43,750/-  to the complainant and  the opposite parties 1&2 jointly and severally liable to pay an amount of Rs.10,000/- as compensation for mental agony of the complainant and Rs.4000/- as litigation cost  within  30 days of  receipt  of this order. In default the amount of Rs.43,750/- carries 12% interest per annum from the date of order till realization.  Failing which the  complainant is at liberty to  execute  the  order as  per the  provisions  of Consumer Protection Act 2019.

Exts:

A1- Bill

A2-Bill(cash receipt)

A3-Discharge summary

A4&A5- Repudiation letter

A6-Policy

A7- copy of lawyer notice

A8-Postal receipt

A9- copy of census conducted by the government.  

B1- Group  medical insurance Policy

PW1-M.T.Vijayan- Complainant

DW1-K.Somanathan Nair- 1^st OP

Sd/                                                         Sd/                                                     Sd/

PRESIDENT                                             MEMBER                                               MEMBER

Ravi Susha                                       Molykutty Mathew                                    Sajeesh K.P

eva           

                                                                        /Forwarded by Order/

                                                                   ASSISTANT REGISTRAR