Kerala

Ernakulam

CC/12/12

P J JOY - Complainant(s)

Versus

THE NEW INDIA ASSURANCE CO. LTD. - Opp.Party(s)

H B SHENOY

30 Jan 2013

ORDER

BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM
ERNAKULAM
 
Complaint Case No. CC/12/12
 
1. P J JOY
S/O OUSEPH, PULIMAPARAMBIL HOUSE, PANAVALLY P.O, CHERTHALA
...........Complainant(s)
Versus
1. THE NEW INDIA ASSURANCE CO. LTD.
REP. BY ITS DEPUTY GENERAL MANAGER, REGIONAL OFFICE, 36/707, KANDAMKULATHY TOWERS, PB NO. 1049, KOCHI -682011
2. TTK HEALTHCARE TPA PVT. LTD.
1400B MAREENA BUILDINGS, M.G ROAD, RAVIPURAM, KOCHI - 682016
3. WELFARE SERVICES
PONNURUNNI, VYTTILA P.O, KOCHI - 682019
............Opp.Party(s)
 
BEFORE: 
 HONORABLE MR. A.RAJESH PRESIDENT
 HONORABLE MR. PROF:PAUL GOMEZ Member
 HONORABLE MRS. C.K.LEKHAMMA Member
 
PRESENT:
 
ORDER

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

 

 
 
[HONORABLE MR. A.RAJESH]
PRESIDENT
 
[HONORABLE MR. PROF:PAUL GOMEZ]
Member
 
[HONORABLE MRS. C.K.LEKHAMMA]
Member

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