DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD
Dated this the 6th day of June 2012
Present : Smt.Seena H, President
: Smt. Preetha.G. Nair, Member
Date of filing : 06/01/2012
(C.C.No.4/2012)
K.T.Ashok,
S/o.K.K.Thankappan,
Kovilingal House,
Tholannur (PO),
Kuthanur, Palakkad - Complainant
(Party in Person)
V/s
The United India Insurance Co.Ltd.,
(Rep.by its Authorized Representative),
Personal Line Insurance Office,
Surya Complex, Mission School Junction,
Palakkad – 678 014 - Opposite party
(By Adv.K.Lakshminarayanan)
O R D E R
By Smt.SEENA.H. PRESIDENT
Complaint in brief:
Complainant availed a medi claim insurance policy from the opposite party in the year 1992 for a period of 1 year which was subsequently renewed from time to time. Complainant has paid premium without any default. On 20/10/2011 complainant was diagnosed with Re-ear Chronic Supprative Otitis Media, attic Pathology + TM adhesive with conductive hearing loss and was admitted at Kovai ENT Research Centre. Complainant incurred medical expense to the tune of Rs.47,882/-. When claimed opposite party has issued a cheque for only Rs.22,522/- and Rs.3,866/-. Since the sum insured is Rs.1,00,000/- opposite party is liable to reimburse the entire treatment expenses met by the complainant. Hence the complaint. Complainant prays for an order directing opposite party to pay the balance amount with 12% interest and Rs.25,000/- as compensation.
Opposite party filed version. Facts are more or less admitted by the opposite party. The only contention of the opposite party is that they have paid the eligible amount to the complainant as per the terms and conditions of the policy. Company after taking into consideration the documents produced and treatment undergone by the complainant, settled the claim for Rs.26,388/-. Claim was settled as per the terms and conditions narrated below.
A. Room boarding and nursing expenses as provided by the hospital not exceeding 1% of the sum insured per day or the actual amount which ever is less. This also includes nursing care, RMO charges, IV Fluids, blood transfusion, injection administration charges and similar expenses.
B. ICU expenses not exceeding 2% of the sum insured per day or actual amount which ever is less
C. Surgeon, anesthetist, medical practitioner, consultants, specialist fees
D. Blood, oxygen, operation theatre charges, surgical appliances, medicines and drugs, diagnostic materials and X-ray, dialysis, chemotherapy, radiotherapy, cost of artificial limbs, cost of prosthetic devices, implants during surgical procedure like pace maker, orthopedic implants, infra cardiac valve replacements, vascular stents.
E. Hospitalization (expenses excluding cost of organ) incurred for / by donor in respect of organ transplant to the insured.
The company has paid Rs.3,000/- towards three days hospitalization as per the terms of the policy against his claim of Rs.6,300/-. The expenses towards purchase of medicine were fully allowed and Rs.2,000/- payable under ICU is also paid. The claim made under the heads multi para monitor and CCD camera with monitor alone was disallowed under the head operation and theatre charges as it is not part of his treatment.
According to opposite party there is no deficiency in service on the part of opposite party in settling the claim of the complainant.
Both parties filed their respective chief affidavit. Ext.A1 to Ext.A11 marked on the side of the complainant. Ext.B1 to B2 marked on the side of the opposite party. Matter Heard.
Issues for consideration are :
1. Whether there is any deficiency in service on the part of opposite party ?
2. If so, what is the relief and cost ?
Issue No. 1 & 2
It is not disputed that the complainant has a valid policy coverage during the period of hospitalization. It is also not in dispute that complainant has claimed Rs.47,882/- and opposite party has sanctioned Rs.26,388/- as per the terms and conditions of the policy. The question to be decided is whether complainant is entitled for the balance claim amount of Rs.21,494/-.
Complainant herein has only stated in the complaint the total expense incurred by him. Under what head, how much amount is claimed etc. is not clear from the complaint. However complainant has not objected the version of the opposite party that against a claim of Rs.6,300/- for 3 days hospitalization, an amount of Rs.3,000/- was sanctioned and for 1 day ICU Rs.2,000/- was sanctioned and expense for purchase of medicine was fully allowed. Ext.A4 is the amount claimed by the complainant for medicines, testing and Doctor fee. Total amount claimed is seen as Rs.47,882/-. In Ext.A4 a final bill is seen for Rs.30,000/- It is not understood what all things are included in it. We find that complainant failed to provide a clear picture as to claims not sanctioned by the opposite party, where as opposite party has stated that they have only rejected the claim for multi para monitor and CCD camera with monitor under the head operation and theatre charges as it is not part of the treatment. Complainant has not produced any evidence to show that it is part of the treatment or whether complainant has undergone any operation. Ext.A1 will go to show that complainant has put in ICU for 12 hrs. for observation. If the said monitor and CCD camera is installed in ICU, it form part of the ICU charges and no separate amount can be claimed for that.
In view of the above discussions we are of the view that complainant miserably failed to prove deficiency in service on the part of opposite party. Hence complaint dismissed.
Pronounced in the open court on this the 6th day of June 2012.
Sd/-
Seena.H
President
Sd/-
Preetha G Nair
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 – Original policy NO.101201/48/10/97/00002464
Ext.A2 – Discharge summary issued by Kovai ENT Hospital & Research Centre
Ext.A3 – True copy of medical report dated 29/10/11
Ext.A4 – True copy of statement of claims submitted by the complainant
Ext.A5 – True copy Health Insurance Policy claim form submitted by the
complainant
Ext.A6 – True copy of letter dated 7/12/11 sent to the opposite party by the
complainant
Ext.A7 – Acknowledgement card received by the complainant.
Ext.A8 – True copy of letter dated 3/1/12 sent to opposite party by the
complainant
Ext.A9 – Acknowledgement card received by the complainant
Ext.A10 – True copy of lawyer notice dated 21/12/11 sent to opposite party
Ext.A11 – Acknowledgement card received by the complainant
Exhibits marked on the side of the Opposite party
Ext.B1 – True copy of the mediclaim insurance policy
no.101201/48/10/97/00002464
Ext.B2 – True copy of the reply notice issued to lawyer notice.
Cost allowed
No cost allowed.
