By Jayasree Kallat, Member:

            The petition is filed by Mrs. Beena Purushothaman, wife of Mr. Pallathil Purushothaman, who was working abroad.  Complaint is filed on behalf of her husband as a beneficiary and as joint policy holder.  As complainant’s husband was a N.R.I. working in Kuwait, he had taken a family insurance policy from the first opposite party under the Pravasi Sureksha Kudumba Arogya scheme with the certificate No. 2000/47/761200/80563(761200). It covered a period of 20-12-2000 to 20-12-2005.  While working abroad the complainant’s husband developed a block in the Pelvic Ureteric junction with non-functioning kidney.  He returned to Calicut and underwent Nephrectomy on 8-3-2002.  Later on he was put under strict medication.  Complainant had intimated the first opposite party immediately, there after advancing claim under the policy.  The first opposite party repudiated the claim.  Complainant had taken Pravasi Sureksha Kudumba Arogya scheme as opposite parties had claimed that this scheme was the most beneficial one to N.R.I.  The certificate of insurance clearly shows that the payee under Kudumba Arogya is Mrs. P. Beena, who is the complainant.  The opposite party has denied insurance under Kudumba Arogya scheme by saying that the policy does not cover the said scheme.  The complainant’s husband had to spend Rs.28443/- for his hospital expenses.  This claim was repudiated by the opposite parties.  The act of the opposite parties amounts to negligence and unfair trade practice and also opposite party was deficient in their service.  The opposite parties are liable to pay compensation to the complainant.

            Opposite party filed a version denying the averments in the complaint except those that are expressly admitted.  The opposite party admits the fact that Pallathil Purushothaman was covered under the Pravasi Sureksha Kudumba Arogya policy for the period from 21-12-2000 to 20-12-05.  The scope of the cover grantedunder the policy is as follows:

 1. Section 1.  Pravasi Sureksha ) Personal Accident Benefits) to

Mr. Purushothaman and his family members.

2.      Section-II. Kudumbarogya (Hospitalisation Benefits)—Nil.

The insured has not availed cover for Kudumbaroghya ie. Cover for hospitalization which is optional under the scheme.  To get coverage under Kudumbarogya scheme separate premium has to be paid for different category of persons.  Pravasi Sureksha scheme is confined only to the N.R.I. Spouse and children whereas Kudumbarogya scheme can also be extended to the parents of the N.R.I.  Pallathil Purushothaman is not entitled to get any benefit under the kudumbarogya scheme as he has not paid the requisite premium for getting benefit under that scheme.  Since the complainant’s husband did not sustain any personal accident while in Kuwait the opposite party is not in a position to extend any benefit under the Pravasi Sureksha scheme for which he was insured.  The claim of Purushothaman was repudiated basing on the facts stated above.  There was no negligence, unfair trade practice or deficiency of service on the part of opposite party.  Opposite party is not liable to pay compensation.  The complaint is liable to be dismissed with cost to opposite party.

            The only point for consideration is whether the complainant is entitled for any relief sought in the petition?

            Complainant was examined as PW1 and Ext.A1 to a11 were marked on complainant’s side.  No oral evidence adduced by opposite party.  Ext.B1 was marked on opposite parties’ side.

            The case of the complainant is that complainant’s husband was working abroad in Kuwait and had taken family insurance policy from the first opposite party under the Pravasi Sureksha Kudumba Arogya scheme.  Policy period covered from 20-12-2000 to 20-12-2005.  The compla8inant’s husband had developed block in Pelvic Ureteric Junction and undergone an operation of Nephrectomy on 8-3-02.  The complainant had intimated the first opposite party and immediately preferred a claim for the hospital charges.  The first opposite party had repudiated the claim.  Opposite party had repudiated the claim on the ground that the complainant’s family members were covered only under Pravasi Sureksha insurance scheme which is an accident insurance policy, and Pallathil Purushothaman and his family were not covered under Kudumba Arogya insurance scheme which covers hospitalization benefit.  Complainant herself had produced the repudiation letter of the opposite party which is marked as Ext.A8.  According to the opposite party the Pravasi Sureksha Kudumbarogya policy has two sections, they are (1) 1. Section 1.  Pravasi Sureksha ) Personal Accident Benefits) to Mr. Purushothaman and his family members.Section-II. Kudumbarogya (Hospitalisation Benefits)—Nil.  The complainant’s husband had opted for the Pravasi Sureksha ( Personal Accident Benefit) and not Kudumbaroghya hospitalization scheme.  Ext.A1 certificate of insurance shows that Section-1 Pravasi Sureksh: P.S.-11 was opted by Purushothaman and paid Rs,.2941/- as premium under P.S.II.  The same Ext.A1 certificate of insurance also shows that Kudumbarogya Nil.  Which means complainant’s husband had opted only Section-1. Ext.A1 also shows that they are not covered under Kudumbaroghya.  Opposite party has produced Ext.B1 document enrollment form which is filled by complainant’s husband. In Ext. B1 the Column (a) Pravasi Sureksha is filled and Col.B Kudumbaroghya left unfilled.  Ext.B1 shows that premium was paid under Sec.1 pravasi Sureksha and no premium was paid under Sect.B Kudumbaroghya.  On a perusal of the documents Ext.A1, Ext.A8 and Ext.B1 goes to show that complainant’s husband has taken insurance policy under Pravasi Sureksha only.  Premium was paid only for Pravasi Sureksha and not for Kudumbaroghya.  As early as 2002 opposite party has informed the complainant’s husband that he and his family are covered only under Pravasi Sureksha insurance scheme, which is an accident insurance policy.  Since complainant’s husband  and family are not covered under Kudumbaroghya insurance scheme which covers hospitalization benefits, the opposite party is not in a position to consider the claim.  Ext.A8 produced by the complainant clearly shows this aspect.  In Ext.A8 opposite party has also stated that in case complainant’s husband had taken any Kudumbarogya policy they were to be submitted along with policy particulars to enable the opposite party to consider the claim.  But the complainant has not taken any steps to show that they have paid premium under the Kudumbarogya hospitalization benefits.  Ext.A10 which is issued by the opposite party in 2005 also mentions the same facts by repudiating the claim.  From the documents Ext.A1, A8, A10 produced by the complainant and Ext.B1 produced by the opposite party the Forum has come to the conclusion that complainant has not paid any premium under Kudumbarogya scheme, which is for hospitalization benefits.  Hence we are of the opinion that the complainant is not entitled to get any relief as sought in the petition.

            In the result the petition is dismissed.

Pronounced in the open court this the 8th day of January 2010.

                               Sd/-                                                   Sd/-

                        PRESIDENT                                       MEMBER

APPENDIX

Documents exhibited for the complainant:

  A1.  Certificate of insurance.

  A2.  Medical Scan Report issued by National Scan and Research Centre, Calicut

          Dt. 2-3-02.

  A3.  Clinical Pathology Report dt, 2-3-02 issued by National Scan and Research Centre,

         Calicut.

  A4.  Stool Routine Examination Report dt. 2-3-02 issued by National Scan and

          Research Centre, Calicut.

  A5.  Urine Report dt. 2-3-02 issued by issued by National Scan and

          Research Centre, Calicut.

  A6 ( 26 in Nos.)  Bills.

  A7.  Receipt dt. 13-3-02 of Urology Services.

  A8.  Letter dt. 25-3-02 issued by New India Assurance Company to the

          Complainant.

  A9.  Copy of Registered Lawyer Notice dt. 31-8-05.

A10.  Reply notice dt. 26-9-05.

A11.  Radiological Consultation request by Department of Clinical Radiology

          Ministry of Health, State of Kuwait dt,. 9-4-01.

Documents exhibited for the opposite party.

B1.  Photocopy of Enrollment Form.

Witness examined for the complainant.

PW1.  Beena Purushothaman ( Complainant)

Witness examined for the opposite party.

            None.

                                                                        Sd/- President

                                    // True copy //

                        (Forwarded/By order)

              SENIOR SUPERINTENDENT.