By Smt. Padmini Sudheesh, President:
The case of complainant is that the complainant has taken a mediclaim policy from the respondent which was valid from 20.12.07 to 19.12.08. At the time of issuing policy the respondent assured the complainant that for any kind of treatment the complainant need not pay in the hospital instead by showing the identity card he will get cashless benefit. The policy taken by the complainant is a renewal policy and for past several years the complainant was renewing the policy. On 2.7.08 the complainant was admitted at Oushadhi Panchakarma Hospital and Research Institute for treating Sandhigatha vatham. At the time of admission the complainant informed the respondents about the treatment. The respondents informed that he cannot avail cashless facility. But the amount incurred will be reimbursed by the respondents. The complainant has admitted upto 15.7.08 and he paid the entire hospital bills amount. There incurred medical expenses for an amount of Rs.17,141.14. The complainant submitted claim before the respondents but the respondents refused the claim and lastly sent a cheque for Rs.6563/-. This is a deficiency in service on the part of respondents. Hence the complaint.
2. The counter of 1st respondent is to the effect that this respondent admits that they have issued a medi care policy for a period from 20.12.07 to 19.12.08. The complainant is also a beneficiary under the policy. The complainant has to prove his hospitalization and the payment of the expenses incurred in the hospital. This respondent denied the claims of complainant such as investigation and lab charges, room charges etc. This respondent acted as per the terms and conditions of the policy. The complainant has accepted the cheque for Rs.6563/- as full and final settlement of the claim. There is no deficiency in service from this respondent. Hence dismiss.
3. The 2nd respondent remained exparte.
4. The points for consideration are that:
(1) Is there any deficiency in service from respondents?
(2) If so reliefs and costs.
5. The evidence consists of Exts. P1 to P5 only. No evidence adduced by respondents.
6. Points: The complainant is claiming the balance amount of the medical expenses which was incurred for him for the treatment of “Sandhigatha vatham”. The first respondent stated that he is entitled for only Rs.6563/- and a cheque for the said amount already paid to him and he is not entitled to get any further amount.
7. It is the case of complainant that as per the policy taken he is entitled for cashless benefit for any kind of treatment at any hospitals. When he was admitted at Oushadhi Panchakarma Hospital the cashless facility was not available. It is his case that the respondents informed that the amount incurred will be reimbursed by them. According to him, Rs.17,141/- was the total expenditure but the 1st respondent has given Rs.6563/- only. He claims the balance amount by way of this complaint.
8. Ext. P2 is the copy of discharge summary by which it can be seen that he was admitted on 2.7.08 and discharged on 15.7.08 from Oushadhi Panchakarma Hospital. Dr. K.S. Rajithan has issued Ext. P2. It is the case of 1st respondent that as per the terms and conditions of the policy the investigation charges and lab charges and room charges were excluded. But Ext. P1 series would show that the investigation was done as per the direction of Dr. Rajithan. More over there is no policy produced by the respondent insurance company to prove that the complainant is not entitled for investigation and room charges. So the complainant is entitled to get the entire amount sought.
8. Ext. P5(a) is the copy of repudiation letter from Medi Assist which is the 2nd respondent. As per this document the claim was rejected by them because the patient has taken treatment from a private ayurvedic hospital which is not payable under the policy. It is also stated in the document that the expenses incurred for Auyrveda/Homeopathic/Unani treatment are admissible upto 25% of the sum insured provided the treatment is taken in a Government hospital. But the Medi Assist remains exparte and no evidence adduced. At the same time the 1st respondent company has taken the contention that as per the policy the lab charges and room charges are excluded. So there are different views on the part of respondents. The respondents failed to establish their own cases also.
9. In the result the complaint is allowed and the first respondent is directed to pay the balance amount of Rs.10,578/- (Rupees ten thousand five hundred and seventy eight only) and the second respondent is directed to pay Rs.5000/- (Rupees five thousand only) as compensation within two months from the date of receipt of copy of this order.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum this the 29th day of September 2012.
