DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD
Dated this the 25th day of February 2013
Present: Smt.Seena.H, President
: Smt.Preetha.G.Nair, Member
: Smt.Bhanumathi.A.K, Member Date of Filing : 21/03/2012
CC No.51/2012
N.Venkitesh,
S/o.P.N.Natarajan,
5/745, Ramanathapuram,
Palakkad Muncipality,
Palakkad. - Complainant
(By Adv.John John)
Vs
1.Manager,
The New India Assurance Co.Ltd.,
Regd.& Head Office,
The New India Assurance Building,
87, M.G.Road,
Fort Mumbai – 400 001
(Adv.C.Mohanram)
2.Manager,
The New India Assurance Co.Ltd.,
N.S.Towers, 1st Floor,
Stadium Bus Stand,
Coimbatore Road,
Palakkad
(Adv.C.Mohanram)
3.The Branch Manager,
TTK Health Care Services P.Ltd.
1400-B Mareena Building,
M.G.Road, Ravipuram,
Ernakulam – 682 016. - Opposite parties
(Adv.Ajitha.A)
O R D E R
By Smt.SEENA.H PRESIDENT
Complaint in short.
Complainant availed a medi claim policy from opposite parties 1 & 2 and opposite party No.3 issued a card bearing No.KOC-NI-00000-000-0005538. The period of the policy was from 22/3/2011 to 21/3/2012. Complainant underwent treatment for twisting injury to knee for the period 26/5/2011 to 31/5/11 for the right knee and for the period 28/10/11 to 1/11/2011 for the left knee in Kovai Medical Centre Hospital, Coimbatore. Complainant incurred an amount of Rs.90,190/- and Rs.99,425/- for the hospitalization for the two instances. Claim form along with requisite documents were filed on 1/6/2011 for the 1st hospitalization and on 2/11/11 for the second hospitalization. Opposite parties neither took any steps to disburse the amount nor sent any reply to the claims. Complainant issued a letter dated 5/11/11 to 3rd opposite party. Further caused a lawyer notice dated 2/1/2012 to the 1st and 3rd opposite parties. Though received, no reply was sent by any of the opposite parties. Act of opposite parties amounts to clear deficiency in service on their part. Hence the complaint. Complainant prays for the claim amount with interest along with Rs.1 lakh compensation and cost.
All opposite parties entered appearance and filed version. Facts of the case are more or less admitted by the opposite parties 1 & 2. Policy and hospitalization during the period of policy is not disputed. Receipt of claim forms for the two hospitalization is also not disputed. According to opposite parties 1 & 2 it is for want of necessary documents from the part of the complainant, both these claim forms were kept in abeyance. Company was always ready to settle the claim provided, the necessary particulars as demanded by the company was produced by the complainant. Though sufficient time was granted complainant failed to furnish the same. Hence complainant is not entitled for any compensation.
3rd opposite party admitted receipt of claim forms. Since there was some suspicious circumstances all the documents were forwarded to 2nd opposite party for investigation. 2nd claim was also kept pending since the earlier one was suspicious. Further stated that as per the policy conditions, the original bills, cash memos and medical records should be submitted alongwith the claim form. Complainant submitted all these documents, but failed to furnish additional particulars requested by the opposite party. Complainant has not furnished any document to prove from where he availed first aid treatment immediately after the accident. The claim was kept in abeyance for want of particulars from the side of the complainant. Hence there is no deficiency in service and complaint is liable to be dismissed.
The evidence adduced by the parties consists of chief affidavits of complainant and opposite parties 1 & 2. Ext.A1 to A50 series marked. Opposite party No.3 has not filed any chief affidavit.
Issues for consideration are
1. Whether there is any deficiency in service on the part of opposite parties ?
2. If so, what is the relief and cost the complainant is entitled to ?
Issue No.1&2
Heard both parties and has gone through the entire evidence on record.
Policy is admitted. Hospitalization during the period of the policy is also an admitted fact. Opposite party No.3 admits receipt of claim form with the requisite documents as per the policy. Also stated that the same was forwarded to 2nd opposite party for further investigation. Policy is not seen repudiated by the company. Instead, according to opposite parties it was kept in abeyance for want of requisite documents from the complainant. According to opposite parties there was some suspicion with respect to the injuries and treatment which warranted additional particulars. Ext.A2 complaint dated 5/11/11 sent by the complainant to opposite party No.3 shows that the 1st claim of the complainant was made on 1/6/11 and nothing was acted upon the same. Surgery undergone at the 2nd instance was also intimated by way of Ext.A2. No positive steps seen to be taken by any of the opposite parties in this regard. Ext.A3 shows that lawyer notice were issued to opposite parties on 2/01/2012 for settling the grievances of the complainant. Though opposite parties vehemently argued that the requisite documents were not sent by the complainant, it is not specifically stated which are the necessary documents in this regard and no letter of intimation has seen to be served on the complainant. Opposite parties has not adduced any evidence to show that any further investigation has been done by them to indentify the veracity of the claims. PW1 has deposed that “അസുഖം മുംപ് ഉണ്ടായിരുന്നു എന്നും അത് മറച്ച് വച്ചാണ് policy എടുതതത് എന്നും പറഞ്ഞാല് ശരിയല്ല” The treated doctor was examined by way of commission and medical records were marked as Ext.A50 series. The relevant portion of the deposition of PW2 is as follows:
Q.3 – On how many occasions you treated the complainant ?
Ans. On 4 times, that is on 12/5/11, 26/5/11, 7/10/11 & 28/10/11
Q.7 – During on the first occasion did he had injury on his left knee ?
Ans. No.
In cross
Q1. You have treated the complainant on 4 occasions and what was the
complaints on 12/5/11 ?
Ans. Pain and swelling on the right knee following a fall from a two wheeler
and it was not a road accident.
Q.2 –Do you mean to say that the complainant had fallen from a two wheeler ?
Ans – Complainant said so
Q.3 – Can you explain the first injury in simple terms ?
Ans – It is tearing of the ligment inside the right knee joint.
Q.4 – Can you explain in the 2nd injury in simple terms ?
Ans – The tearing of medial and lateral meniscus.
Q.7 –The patient was treated on the 2nd time for the very same complaint on
the left knee ?
Ans – Yes
Q.8 – You have suggested that the 1st period of treatment the patient had to
give stress on left leg for a period of five weeks after surgery ? Do you
mean that this would have resulted in the compliant on the left knee ?
Ans – No. The five weeks period would be over in July 2011.
It can be seen that the statement of PW2 will rule out any possibility of pre existing disease. In fact opposite parties has not repudiated the claim on this ground also. The evidence on record clearly shows that the opposite parties has withheld the claim of the complainant on flimsy reasons. The deficiency in service on the part of all the opposite parties is crystal clear, for which complainant has to be adequately compensated.
In the result, complaint allowed. Opposite parties are jointly and severally directed to pay complainant an amount of Rs.(Rs.90,190 + Rs.99,425) Rs.1,89,600/- (rounded off) (Rupees One lakh eighty nine thousand and six hundred only) alongwith 12% interest from 2/11/2011 to the date of order and Rs.5,000/- (Rupees Five 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 25th day of February 2013.
Sd/-
Seena H
President
Sd/-
Preetha G Nair
Member
Sd/-
Bhanumathi.A.K.
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 – Insurance Policy dated 22/3/11 issued by opposite party to the
complainant (Photocopy)
Ext.A2 –Copy of letter dated 5/11/2011 issued by the complainant to 3rd
opposite party
Ext.A3 – Copy of Lawyer notice dated 2/1/12 issued by the complainant to the
1st and 3rd opposite parties.
Ext.A4 – Postal receipts dated 3/1/12 (2 in nos)
Ext.A5 – Postal acknowledgement dated 4/1/12
Ext.A6 – Postal acknowledgement dated 9/1/12
Ext.A7 – Photocopy of medical certificate dated 1/11/2011
Ext.A8 – Photocopy of claim form dated 2/11/11
Ext.A9 – Photocopy of the Attending Doctor’s Report dated 1/11/2011
Ext.A10 series – Photocopy of the cash bills ( 3 in nos) dated 7/10/11
Ext.A11 – Photocopy of MRI Scan report dated 7/10/11
Ext.A12 series – Photocopy of the laboratory report (2 in nos) dated 1/11/11
Ext.A13 – Photocopy of the discharge summary dated 1/11/11
Ext.A14 –Photocopy of detail bills ( 8 in nos) dated 1/11/11
Ext.A15 –Photocopy of the cash bill dated 12/5/11
Ext.A16 series – Photocopy of the summary bills (2 in nos) dated 31/5/11
Ext.A17 – Photocopy of the Radiology request form dated 12/5/11
Ext.A18 – Photocopy of claim form dated 1/6/11
Ext.A19 – Photocopy of attending doctor’s report dated 31/5/11
Ext.A20 – Photocopy of discharge summary dated 31/5/11
Ext.A21 –Photocopy of the services detail bills dated 31/5/11
Ext.A22 series – Photocopy of the detail bills (5 in nos) dated 31/5/11
Ext.A23 – Photocopy of the laboratory report dated 31/5/11
Ext.A24 – Photocopy of the MRI Scan report dated 30/5/11
Ext.A25 –True copy of MRI scan report dated 30/5/11
Ext.A26 series – True copy of the laboratory report dated 26/5/11 (2 in nos)
Ext.A27 – True copy of the discharge summary dated 31/5/11
Ext.A28 series – True copy of summary bills (2 in nos) dated 31/5/11
Ext.A29 series – True copy of the detail bill (2 in nos) dated 31/5/11
Ext.A30 series – True copy detail bills (4 in nos) dated 31/5/11
Ext.A31 series – Copy of the daily accounting sheet issued by Department of
posts India dated 2/6/11
Ext.A32 – True copy of the Medical Certificate dated 1/11/11
Ext.A33 – True copy of MRI Scan report dated 7/10/11
Ext.A34 – True copy of discharge summary dated 1/11/11
Ext.A35 – True copy of Laboratory report dated 29/10/11
Ext.A36 series – True copy of Summary bills (2 in nos) dated 1/11/11
Ext.A37 – True copy of Service detail bills (2 in nos) dated 1/11/11
Ext.A38 – True coy of detail bills (4 in nos) dated 1/11/11
Ext.A39 –Copy of the Daily Accounting Sheet issued by Department of Post India
dated 7/11/11.
Ext.A40 – Discharge summary dated 1/11/11
Ext.A41 –MRI Scan report dated 7/10/11
Ext.A42 –Laboratory Report dated 1/11/11
Ext.A43 –Summary bills dated 1/11/11
Ext.A44 –Cash receipt dated 1/11/11
Ext.A45 –Detail bills dated 1/11/11
Ext.A46 –Medical bill for Rs.418/- dated 7/10/11
Ext.A47 –Bill for MRI scan dated 7/10/11
Ext.A48 –Cash bill for doctors fee and Radiology dated 7/10/11
Ext.A49 –Medical Certificate dated 1/11/11/
Ext.A50 series – Document marked by Commissioner (Patient treatment details)
Exhibits marked on the side of the opposite party
Nil
Witness examined on the side of the complainant
PW1 – N.Venkitesh
PW2 – Dr.S.G.Thirumalai Samy
Cost
Rs.5,000/- allowed as cost of the proceedings.
