IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 31stday of March, 2022
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anot, Member
C C No. 71/2021 (filed on 30-03-2021)
Petitioner : Sugunan K.
Karoth House,Velloor P.O.
Pampady Village,
Pin – 686 501.
(Adv. S. Pradeep Kumar)
Vs.
Opposite party : The Deputy General Manager,
Oriental Insurance Co.Ltd.
Regional Office, Metro palace,
Opp. North Railway Station,
Ernakulam - 682018
(Adv. P.C.Chacko)
O R D E R
Sri. Manulal V.S. President
The case of the complainant is as follows:
Complainant is the father and guardian of late ShijuK. Suganan, whowas a differently abled person and he was 75% disabled.Complainant had taken Niramaya Policy which is a social security measurefor the benefit of the differently abled persons from the office ofthe opposite party. The policy covered the medical treatment ofthe insured. In the month of July 2018 the insured washospitalized for treatment and on 3-7-2018 to 4-7-2018 he wastreated as inpatient at Base hospital, Manarcadu and Rs.5,659/-was paid for treatment expenses. Again on 19-11-2018 he wasadmitted in the same hospital for treatment and admitted till 23-11-2018 and an amount of Rs.13,804/- was incurred for thetreatment.Unfortunately insured was expired on 29-11-2018.
Complainant submitted two claim before the opposite party fora total sum of Rs.19,564/- and all relevant documents andoriginal treatment records and medical bills were submitted alongwith application. It is alleged in the complaint that the oppositeparty was reluctant to settle the claim and repeatedlydemanding unnecessary documents including the deathcertificate of the insured. The complainant responded to allnotices and resubmitted the copy of treatment certificate andcancelled cheque again and again, the opposite party failed tosettle the claim.
Then the complainant filed a petition before InsuranceOmbudsman and on 11-8-2020 the insurance ombudsman passedan award directing the opposite party to pay the admissibleamount within 30 days, but till the date opposite party did notcomply the order. Thereafter the complainant sent a letter to theC.M.D. of the opposite party but no response. Thought thenotice to the Prime minister by the complainant was forwardedto the opposite party, it was also in vain. Hence this complaint.
Though the notice was duly served to the opposite party, theopposite party failed to appear before the Commission and file version.
Thus the opposite party was declared as ex-party.
Complainant filed proof affidavit in lieu of chief examinationand exhibits A1 to 20 were marked.
Point for consideration.
Whether the complainant had succeeded to prove deficiency inservice on the part of the opposite party and entitled for anyreliefs?
Points
Complainant is the father and guardian of late Shiju .K. Suganan, whowas a differently abled person and having 75% disability.According to the complainant he had taken Niramaya Policywhich is a social security measure for the benefit of the differently abledpersons from the office of the opposite party in the name of thesaid Shiju .K. Suganan . Exhibit A1 is the photo copy ofthe policy bearing no. C214600/48/2019/100. Exhibit A2 is theidentity card issued by the Department of social justice in thename of the said Shiju .K. Suganan. The policy covered themedical treatment of the insured.
It is proved by exhibit A3 and A4 that the insured was treated inthe Base hospital as inpatient from 3-7-2018 to 4-7-2018 and19-11-2018 to 23-11-2018 respectively. The first admission wasdue to Hydrocephalus and second admission with complaint ofviral fever. Shiju .K. suganan was died on 29-11-2018.Complainant being the beneficiary of the insured filed twoclaims before the opposite party for the refund of expensesincurred by him for the treatment of the insured. On 16-1-2018the third party administrator of the opposite party issued ExhibitA6 letter to the complainant requesting to produce cancelledcheque with the name of the beneficiary and bank details tohounor the claim no. 556271819370901 for an amount of Rs.13084. Complainant along with exhibit A7 cover letter sentthese documents to the third part administrator on 20-2-19 andexhibitA9 postal receipt proves the issuance of same. Afterthat on 17-12-2019 opposite party sent exhibit A12 letter statingthat the claim no. 556271819370901 for an amount of Rs.13084/- was repudiated due to non-receipt of documents by third partyadministrator and further demanded original discharge summary dated 3-7-2018 to honour the claim 556271819369239 .
According to the complainant the opposite party evaded from settling the claim by repeatedly demanding unnecessarydocuments including the death certificate of the insured.
Aggrieved by the act of the opposite party complainant filed apetition before the insurance ombudsman and ombudsman videexhibit A13 order dated 11-8-2020 directed the opposite party topay the admissible amount within 30 days from the receipt ofdeath certificate and original discharge summary from thecomplainant. Thereafter on 26-8-2020 opposite party issuedExhibit A15 letter to the complainant demanding affidavit oflegal nominee and original Discharge Summary for thehospitalization dated 3-7-2018 and break up of main HospitalBill. According to the complainant he had sent all the relevantdocuments to the opposite party on 24-8-2018 and exhibit A14postal receipt and A/D card proves the receipt by the oppositeparty. There is no contrary evidence before us to rebut theevidence adduced by the complainant. Thus we are of the
opinion that the conduct of the opposite party amounts toimperfection inadequacy in service offered to the complainantand amounts to deficiency in service.
No doubt complainant had suffered much mental agony andhardship due to the deficient act of the opposite party. It isclassic example for the mechanical approach of the insurancecompany and how they are treating the social welfare schemewhich were in-corporated by the state for safeguarding theweaker class of people including the differently abled person. Inplethora of judgments the apex commission and Hon’bleSupreme Court has held that for the deficiency of service theconsumer shall reasonably be compensated by the serviceprovider or the person had committed the deficient act.
Considering the nature and circumstance of the case we are ofthe opinion that the complainant is entitled for thereimbursement of the medical expenses incurred by him for thetreatment of Shiju .K. Suganan along with a compensation of Rs.25,000/.
Therefore we allow the complaint and pass the following order.
1. We hereby direct the opposite party to pay Rs.19564/- with 9 % from 30-3-2021 ie. the date on which thecomplaint is filed by the complainant.
2. We hereby direct the opposite party to pay Rs.25,000/- ascompensation to the complainant for the deficiency inservice committed by the opposite party.
Order shall be complied within a period of 30 days from the date of receipt of Order. If not complied as directed, the award amount will carry further 9% interest till realization.
Pronounced in the Open Commission on this the 31st day of March, 2022
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant.
A1- Photocopy of policy (C214600/48/2019/100)
A2- Photocopy of ID card for person with disabilities
A3- Photocopy of discharge summary from Base Hospital dtd.04-07-18
A4 – Photocopy of discharge summary dtd.23-11-18
A5-Photocopy of claim form and postal receipt dtd.15-12-18
A6- Letter dtd.16-01-19 to Shyju K. Sugumon
A7-Phtocopy of letter dtd.19-02-19 by complainant
A8 – Photocopy of Electronic clearing service (Credit clearing) mandate form
A9- Postal receipt dtd.20-02-19
A10- Postal receipt with acknowledgement card
A11- Postal receipt with acknowledgement card
A12-Letter dtd.17-12-19 issued by opposite party to complainant
A13-Award dtd.11-08-2020 from the Insurance Ombudsman
A14- Postal AD card and postal receipt
A15 – Letter dtd.26-08-20 issued by opposite party
A16- Postal receipt
A17-Postal acknowledgement card and postal receipt
A18- Letter dtd.21-10-2020 by opposite party to complainant
A19-Postal receipt and acknowledgement card
A20- Letter from Prime Minister’s Office to complainant
By Order
Assistant Registrar
