BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,
ERNAKULAM.
Date of filing : 24/08/2010
Date of Order : 30/11/2011
Present :-
Shri. A. Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member.
C.C. No. 260/2010
Between
James. A.V., | :: | Complainant |
Alukka House, Anicadu, Avoli. P.O., Muvattupuzha. |
| (By Adv. Tom Joseph, Court Road, Muvattupuzha – 686 661 |
And
1. M/s. United India Insurance Co. Ltd., | :: | Opposite parties |
Branch Office, Municipal Shopping Complex, Kacherithazham, Muvattupuzha. 2. M/s. Dedicated Healthcare Service TPA (India) Pvt. Ltd., G-A, Saniya Apartments, Asoka Road, Kaloor, Kochi – 682 017. |
| (Op.pty by 1 Adv. Lakshmanan. T.J., Penta Queen, Padivattom, Kochi – 24)
(2nd op.pty absent) |
O R D E R
A. Rajesh, President.
1. Briefly stated, the facts of the complainant's case are as follows :
The complainant is a mediclaim insurance policy holder issued to M/s. Rubber Growers and Processors Association, since 20-12-2007 issued by the 1st opposite party. The facts while so, the complainant noticed blood contamination in his urine and he approached the Specialist Hospital, Ernakulam and his disease was diagnosed as Haematuria. He was treated as inpatient from 14-09-2009 to 18-09-2009. He spent Rs. 12,408/- towards treatment expenses. Again, he was treated at the hospital as inpatient from 05-10-2009 to 12-10-2009. He spent Rs. 35,717/- during the second hospitalisation. Accordingly, the complainant submitted a claim application before the 1st opposite party. The 1st opposite party closed the processing of the claim application for their own reasons. The complainant is entitled to get Rs. 48,125/- being the treatment expenses incurred by him together with interest and compensation of Rs. 10,000/-.
2. The version of the 1st opposite party is as follows :-
The policy was issued for the period from 20-12-2007 to 19-12-2008, and thereafter, the policy was renewed every year. As per the medical certificate, the complainant had consulted the doctor on 14-03-2007 prior to the inception of the policy. As per clause 4.3 of the policy, the treated illness is excluded for 2 years from the date of commencement of the policy. After receipt of the claim application, the 2nd opposite party intimated the complainant to produce the documents to process the claim application in which the complainant failed. So, the opposite party was constrained to close the processing of the claim application. There is no deficiency of service on the part of the opposite party.
3. In spite of service of notice from this Forum, the 2nd opposite party did not respond to the same for their own reasons. No oral evidence was adduced by the complainant. Exts. A1 to A4 were marked on his side. Witness for the 1st opposite party was examined as DW1. Exts. B1 to B6 were marked on the side of the 1st opposite party. Heard the counsel for the complainant and the 1st opposite party.
4. The points that arose for consideration are as follows :-
Whether the complainant is entitled to get a sum of Rs. 48,125/- towards treatment expenses from the opposite parties?
Compensation and costs of the proceedings?
5. Point No. i. :- Admittedly, the complainant is a beneficiary of the policy availed by M/s. Rubber Growers and Processors Association. It has been in force since 20-12-2007 wihtout break.
6. The 1st opposite party vehemently contended that the complainant was undergoing a treatment even prior to the inception of the policy and so the 1st opposite party is not liable to pay any insurance claim to the complainant as per the terms and conditions of the policy. However, they have failed to prove that the so called previous ailment is necessarily the reason for turning down the claim of the complainant, especially so in view of the expert opinion of DW1. During examination, DW1 categorically stated that the present ailment which the 1st opposite party claims as being pre-existing has no connection with the previous ailment which the complainant had. This has not been controverted, so the contention of the 1st opposite party to the contrary goes.
7. The complainant has not produced any document before this Forum to prove that he had to expend Rs. 48,125/- towards his treatment expenses. The complainant would have produced the same before the opposite party during the initial processing of the claim application to which there is no controvertion.
7. Be that as it may, we direct the 1st opposite party to pay the insurance claims of the complainant as per norms provided the complainant submits the relevant documents to substantiate the quantum of expenses incurred by him during his treatment at the hospital.
8. Point No. ii. :- The petitioner not having produced the primary records for the claim of compensation and costs, this Forum is ill at ease to award the same. Reasons upheld.
9. In the result, we partly allow the complaint and direct that the 1st opposite party shall pay the insurance claims of the complainant as per norms provided the complainant submits the relevant documents to prove the quantum of expenses incurred by him for his treatment.
The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.
Pronounced in open Forum on this the 30th day of November 2011.
Sd/- A. Rajesh,President.
Sd/- Paul Gomez, Member.
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent
A P P E N D I X
Complainant's Exhibits :-
Exhibit A1 | :: | Copy of the letter dt. 27-03-2010 |
“ A2 series | :: | Copy of certificate of insurance (3 Nos.) |
“ A3 | :: | Copy of treatment reports |
“ A4 series | :: | Copy of case summary and hospital records issued from the Specialist Hospital |
Opposite party's Exhibits :-
Exhibit B1 | :: | Medical report of the complainant |
“ B2 | :: | Copy of the letter dt. 19-12-2009 |
“ B3 | :: | A letter dt. 17-12-2009 |
“ B4 | :: | Claim form dt. 23-10-2009 |
“ B5 | :: | Copy of discharge summary |
“ B6 | :: | Copy of policy conditions |
Depositions :- |
|
|
PW1 | :: | Dr. Vijayan – Witness of the 1st op.pty |
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