cccccPBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 30th day of January 2013
Filed on : 09/01/2012
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member
C.C. No. 12/2012
Between
P.J. Joy, : Complainant
S/o. Ouseph, (By Adv. H.B. Shenoy, M/s. H.B.
Pulimparambil house, Shenoy Associates, “Sudarsan”,
Panavally P.O., Cherthala. Krishnaswamy road, Ernakulam,
Kochi-682 035)
And
1. The New India Assurance Co. : Opposite parties
Ltd., rep. by its Deputy General (1st O.P. by Adv. P.G. Ganapapan
Manager, Regional Office, Anjali, Thrikkakara P.O, Ernakulam,
36/707, Kandamakulathy Towers, Kochi-21)
P.B. No. 1049, Kochi-682 011.
2. TTK Healthcare TPA Pvt. Ltd., (2nd and 3rd O.P. absent)
1400B Mareena Buildings,
M.G. road, Ravipuram,
Kochi-682 016.
3. Welfare Services,
Ponnurunni, Vyttila P.O.,
Kochi-682 019.
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
The complainant is an employee of Deepika daily. The complainant had through the 3rd opposite party availed of a family medi-claim insurance policy of the 1st opposite party with insurance coverage of Rs. One lakh for the period from 07-01-2011 to 06-01-2012. During the currency of the policy the complainant’s father Mr. Ouseph fell down and sustained injuries resulting in hospitalization from 11-03-2011 to 21-03-2011 in KVM Hospital Cherthala. The complainant incurred an amount of Rs. 81,227/- towards treatment expenses. Against the said bill the 1st opposite party through the 2nd opposite party paid only Rs. 33,704/- to the hospital. The complainant on his own paid the balance amount of Rs. 39,938/-. The complainant’s father died on 23-04-2011. Subsequently the complainant lodged claim for the balance amount of Rs. 39,938/-. But despite repeated requests and reminders the opposite parties did not take any action. Thus the complainant is before us seeking direction against the opposite parties to pay the balance insurance claim together with compensation and costs of the proceedings.
2. The version of the 1st opposite party is as follows:
The 1st opposite party issued a group insurance medi claim policy in favour of the 3rd opposite party and the complainant and his family members are beneficiaries to the same. The liability of the 1st opposite party is subject to the terms and conditions of the policy and the memorandum of agreement entered into between the 1st opposite party and the 3rd opposite party. The 2nd opposite party received a pre authorization request from the Hospital in connection with the treatment of the complainant’s father. The 3rd opposite party approved an amount of Rs. 33,740/- on the basis of the terms and conditions of the policy. After discharge the complainant submitted claim application for the remaining amount of Rs. 39,938/-. The 1st opposite party granted a further amount of Rs. 216/- and rejected the remaining claim as per the terms and conditions and maximum limit of the policy. There is no deficiency in service on the part of the 1st opposite party. The complaint is liable to be dismissed against the 1st opposite party.
3. Despite service of notice from this Forum the 2nd and 3rd opposite parties opted to remain absent during the proceedings for their own reasons. The complainant was examined as PW1 and Exts. A1 to A5 were marked. No oral evidence was adduced by the 1st opposite party. Ext. B1 was marked. Heard the counsel for the complainant and the 3rd opposite party.
4. The points that arose for consideration are
i. Whether the complainant is entitled to get the balance
insurance claim of Rs. 39,938/- from the opposite parties?
ii. Whether the opposite parties are liable to pay compensation
and costs of the proceedings to the complainant?
5. Point No. i. It is not in dispute that the complainant had to spend Rs. 81,227/- towards treatment expenses of his father at KVM hospital, Cherthala evident from Ext. A4. It is also not in dispute that the 1st opposite party paid Rs. 33,704/- against the claim of Rs. 81,227/-. The request for the remaining insurance claim has been repudiated by the 1st opposite party. According to the 1st opposite party they have paid the insurance claim in terms of Ext. B1 the memorandum of understanding entered by the opposite parties. Indisputably the liability of the 1st opposite party is limited to the terms and conditions of the policy. The 1st opposite party has extensively quoted the calculation statement in their version to arrive at the payment of insurance amount. Evidently the calculation statement is strictly in terms of Ext. B1 except the period of IP treatment of the complainant’s father. Exbt. A4 certificate goes to show that the complainant’s father had undergone IP treatment from 11-03-2011 to 21-03-2011 i.e. for ten days. However instead the 1st opposite party calculated only 8 days I.P to arrive at the insurance amount. Legally the complainant is entitled to get the benefits of the insurance policies for 10 days I.P. treatment of the complainant’s father. In the above circumstances we are only to direct the 1st opposite party to pay the balance insurance claim on the basis of the calculation of the insurance claim for 10 days instead of 8 days.
6. Point No. ii. The primary grievance of the complainant having been met no question of any compensation and costs of the proceedings necessarily arises.
7. In the result, we partly allow the complaint and direct that the 1st opposite party shall pay the balance insurance claim of the complainant considering the inpatient treatment for 10 days instead of 8 days together with interest @ 12% p.a. from the date of complaint till realization with the above directions the proceedings in this complaint stands closed.
The above said order shall be complied with within a period of thirty days from the date of receipt of a copy of the order.
Pronounced in the open Forum on this the 30th day of January 2013.
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits :
Ext. A1 : Copy of health card
A2 : Copy of health card
A3 : I.D. card of KVM Hospital
A4 : Copy of authorization
A5 : Copy of letter dt. 12-07-2011
Opposite party’s Exhibits : :
Ext. B1 : Copy of Memorandum
Depositions:
PW1 : P.J. Joy