DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  4^th  day of  August, 2023 

Present      :   Sri. Vinay Menon V., President

                   :   Smt. Vidya A., Member

                  :   Sri. Krishnankutty N.K., Member                               Date of Filing:  10/02/2022     

                                                                                  CC/29/2022

Rameshkumar @ Ramesh,

C/o.Mangapallam Milk Producers

Co-Op Society, Mangapallam,

R.V.Pudur, Eruthiyampathy,

Vadakarapathy, Palakkad – 678 555.                          -                     Complainant

(By Adv. K.V.Sujith)

                                                                                                Vs

The Branch Manager,

M/s. Star Health & Allied Insurance Co. Ltd.,

Branch Office, 1^st Floor, R.K. Buildings,

Opp. Chitturkavu, Chittur, Palakkad – 678 101.         -                       Opposite party  

(By Adv. M/s.P.Ratnavally & Kiran G Raj A)

O R D E R

By  Sri. Vinay Menon V., President  

1. Pleadings of complainant, abridged, are that the complainant was  a beneficiary under the family health Optima Policy issued by the opposite party covering 17/8/2020 to 16/8/2021. From 6/5/2021 to 11/5/2021 the complainant was treated as inpatient in Alva Hospital Pvt. Ltd., and incurred an expense of Rs.1lakh. The claim was rejected by opposite party on the ground that the type of treatment necessary for treatment for the Covid-19 suffered by the complainant need only self isolation by home quarantine.  On that ground, the claim was rejected. Aggrieved thereby, this complaint is filed seeking  Rs.1 lakh and other incidental expenses.
2. Pleadings are undisputed except that the opposite party stuck to their guns stating that the admission and treatment rendered to complainant was totally unnecessary in view of the guidelines issued by the Govt. and other authorities. They sought for dismissal of the complaint.
3. The following issues were framed for consideration:

1. Whether the condition of the complainant warranted hospitalization ?
2. Whether the repudiation of claim by the opposite party  was in accordance with terms and conditions of the policy ?
3. Whether there is any deficiency in service / unfair trade practice on the part of OP in repudiating the claim ?
4. Whether the complainant is entitled to any reliefs sought for ?
5. Any other reliefs?

4.         (i)         Complainant filed proof affidavit and marked Ext.A1 to A5.   Marking of Ext.A1 to            A4 were objected as they are photocopies. Since this Commission not bound by       the principles of Indian Evidence Act and in the absence of any allegation that            the  said documents were fabricated this objection is over ruled.

(ii)        OP filed proof affidavit. Exts. B1 to B3 were marked.

Issue No. 1

5.         Ext.A2 is the discharge summary pertaining to the treatment received by the complainant in the treating hospital. He had undergone treatment for category-2 Covid disease. It is the case of opposite party that the conditions suffered by the complainant did  not warrant hospitalization, based on the guidelines issued by the Govt. of Kerala as well as the Ministry of Health and Family Welfare, Govt. of India.

6.         When the O.P. had raised a strong pleading that for the condition suffered by the complainant, hospitalization was not required, it was the incumbent duty on the part of the complainant to prove his case by adducing evidence like examination of the treating doctor to prove that the complainant’s condition warranted hospitalization.

7.         This Commission, being laymen insofar as medical intricacies are concerned, cannot jump to a conclusion that the decision of the treating doctor to admit the complainant was  unnecessary or necessary based merely on the entries in  Ext.A2. Other exhibits also do not prove that the complainant required admission.

8.         Thus we hold that the complainant has failed to prove that the complainant required hospitalization. 

Issue Nos. 2 & 3

 9.        Resultantly, we reiterate that the complainant has failed to prove that repudiation was contrary to the insurance contract and that there was deficiency in service on the part of the O.P. in repudiating the claim of the complainant.

            Issue Nos. 4 & 5

10.       Naturally the complainant is not entitled to any of the reliefs sought for.

11.       Considering the facts and circumstances of the case, parties are directed to suffer their respective costs.

12.       The complaint stands dismissed.

                  Pronounced in open court on this the  4^th  day of August,  2023.    

                                                                                                                                  Sd/-

                                                                                                            Vinay Menon V

                                                                President

                                                                                  Sd/-

                                                            Smt. Vidya A.

                                                                Member

                        Sd/-

              Krishnankutty N.K.

                                                                                                                     Member

APPENDIX

Exhibits marked on the side of the complainant :

Ext.A1 – Copy of policy certificate bearing No.P/181226/01/2021/001574

Ext.A2 – Copy of discharge summary dated 11/5/2021

Ext.A3 – Copy of CT Scan result dated 5/5/2021

Ext.A4 – Original certificate issued by Dr. Vasanthkumar Alva

Ext.A4 – Copy of repudiation of claim

 Exhibits marked on the side of the opposite party:

Ext.B1 –  Copy of policy document     

Ext.B2 –   Copy of discharge summary

Ext.B3 –   Copy of repudiation of claim

Court Exhibit:  Nil

Third party documents:  Nil

Witness examined on the side of the complainant:  Nil

Witness examined on the side of the opposite party: Nil

Court Witness: Nil

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.