CONSUMER DISPUTES REDRESSAL FORUM
PALAKKAD, KERALA
Dated this the 15th day of June, 2012.
Present: Smt. Seena. H, President
: Smt. Preetha. G. Nair, Member
: Smt. Bhanumathi. A.K, Member Date of filing: 27/06/2011
CC / 94/ 2011
Sajeeshkumar.S,
LRs.
1.Sivankutty, S/o.S.Kesavan Nair
2. Sathybhama W/o.Sivankutty
3. K.T.Salini,W/o.Sajeeshkumar.S - Complainants
4. Adithyan S/o.Sajeeshkumar.S
5. Aryananda D/o.Sajeeshkumar.S
(Minors 4 & 5 rep.by the guardian mother K.T.Salini)
6.Sajithakumari W/o.Jayaprakash
all residing at Mannath House,
Vasudeva Nagar, Robinson Road, Palakkad.
(BY ADV. T.V.Krishnadas)
Vs
1.Managing Director/Authorised Signatory,
M/s. Metlife Insurance Co. Ltd,
Thadikaran Centre, II nd Floor,
Palarivattom, Kochi- 682 025
(BY ADV. P.Fazil)
2. The Manager
M/s. Metlife Insurance Co. Ltd,
Chandranagar, Palakkad. - Opposite parties
(BY ADV. P.Fazil)
3.Director/Authorised Signatory,
M/s.United Health Care India, Unit.No.3A, 34 Floor,
Gundecha Enclave, Kherani Road, Sakinaka,
Andheri (E), Mumbai-400 072
O R D E R
BY SMT. SEENA.H, PRESIDENT
The complainants herein are the legal heirs of deceased original complainant impleaded as per order in IA/595/11.
Complaint in brief:
Original complainant was the employee of opposite party company since 8/7/2009. As per the terms and condition of employment opposite party is providing insurance policy coverage for Rs.3 lakhs to its employees without any reservation and restrictions for all medical treatment. During the continuance of the employment complainant was admitted in Amritha Hospital, Kochi for a serious heart disease known as 'Biventricular EMF'. Complainant underwent AICD implantation on 5/5/2010 and was discharged on 11/5/2010. An amount of Rs.5,65,423/- was spent for treatment. Claim petition was filed before the opposite party. Opposite party allowed only a part claim of Rs.64,350/- & Rs.27,988/-, there by withholding a major portion of the claim amount. The act of opposite parties has resulted in huge financial loss & tremendous mental agony to the deceased complainant. Hence the complaint. Complainant prays for the balance claim amount of Rs.2,07,662/- along with cost & compensation.
Opposite party No.3 set exparte. Opposite party 1 & 2 filed version. Opposite parties admitted that the complainant was their employee & he resigned from opposite party company on 2/7/10. Opposite party also admits the medical insurance policy provided to its employees. Payment is subject to submission of claim form along with supporting documents. It is also admitted that complainant made a claim for Rs.5,66,081/-. On scrutiny of the claim complainant was asked to provide the following documents viz, tax invoice of Rs.4,91,589/- charged for pacemaker, break up of bill of Rs.9,029/- & investigation reports along with ECG and X-ray report. Complainant has not submitted the complete set of documents as requested. Hence the claim was partialy allowed & several reminders were sent on 4/06/10, 7/06/10, 10/06/10 & also on 14/06/10 through e-mails & phone for the submission of documents. Complainant has not submitted the same. Again requests were made on 15/06/10, 21/06/10, 29/06/10 for which complainant agreed to submit the documents every time, but has not submitted. Due to non-receipt of the mandatory documents, claim was closed on 28/08/10 & the same was informed to the complainant. Hence there is no deficiency in service on the part of opposite party 1 & 2.
The evidence adduced by the parties consists of chief affidavit of complainant and opposite parties 1 & 2, Ext.A1 to A8 marked on the side of the complainant and Ext.B1 & B2 marked on the side of opposite parties 1 & 2.
Now the issues that arise for consideration are
1. Whether there is any deficiency in service on the part of opposite party?
2. If so, what is the reliefs and cost complainant is entitled to?
Issue No.1 &2
The deceased complainant was an employee of opposite party. It is evident from Ext.A5. During the period of hospitalization in the month of May 2010 also, complainant was under the employment of opposite party. Opposite party has admitted the receipt of claim form for Rs.5,66,081/- but has contented that the complainant failed to submit certain receipts requested by the opposite parties. Sanctioning of part of the claim is done by the opposite parties and complainants has admitted receipt of Rs.92,338/- as claim in part. Opposite parties 1 & 2 has contented that they have sent a series of letters on various dates requesting complainant to produce the receipt as requested, but complainant did not turn up. We find it difficult to believe the said version in the absence of any evidence. Opposite parties 1 and 2 has not produced copy of any single letter or e-mail before the forum. It is also hard to believe that opposite party without receipt of the documents sanctioned part claim. If the opposite party has sanctioned part claim, it can only be presumed that it was done after receipt of the entire documents. The act of opposite parties in withholding the balance claim amounts to clear deficiency in service on their part.
In the result complaint allowed. All opposite parties are jointly and severally directed to pay complainant an amount of Rs. 2,07,662/- being the balance claim amount together with Rs.5000/- (Rupees Five thousand only) as compensation and Rs.1000/-(Rupees Thousand only) as cost of the proceedings.
Order shall be complied within one month from the date of receipt of order, failing which the complainant is entitled for 9% interest per annum for the whole amount from the date of order till realization.
Pronounced in the open court on this the 15th day of June, 2012
Sd/-
Smt. Seena. H
President
Sd/-
Smt. Preetha.G.Nair
Member
Sd/-
Smt. Bhanumathi.A.K
Member
A P P E N D I X
Exhibits marked on the side of complainant
Ext. A1 –Discharge summary of Sajeeshkumar.S dt.05/05/2010
Ext. A2 – Axis Bank's Statement of account
Ext. A3 – Axis Bank's pay in slip Rs.61,268/-
Ext.A4– E-mail
Ext.A5- Appointment letter of Metlife
Ext.A6- Claims Detail View
Ext.A7- Claims Detail View
Ext.A8 – Group mediclaim policy (2007) of The New India Assurance Co.Ltd (Attested copy)
Exhibits marked on the side of opposite party
Ext. B1 – Letter of Metlife, Bangalore to Sajeeshkumar.S dt.20-Aug-2010.
Ext. B2 – Letter of Metlife, Bangalore to Sajeeshkumar.S dt.06-Sep-2010.
Witness examined on the side of complainant
Nil.
Witness examined on the side of opposite party
Nil
Cost allowed
Rs. 1000/- allowed as cost of the proceedings.
