BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 30th day of September 2011
Filed on : 07/06/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member.
C.C. No. 290/2011
Between
K.R. Subash, : Complainant
Advocate, Karuvelil house, (By Adv. P.M. Saji,
Ponnurunni, Narayanansan Neethi Bagh, Sastha Temple road,
road, Vyttila P.O., Kochi-19. Kaloor, Cochin-17)
And
1. United India Insurance : Opposite parties
Company Ltd., 24, Whites road, (Ex-parte)
Chennai-600 014, rep. by
Chairman cum Managing
Director.
2. The Branch Manager,
United India Insurance
Company Ltd., Vettukattil
Building, M.G. Road,
Ernakulam, Kochi-682 016.
3. M/s. TTK Healthcare TPA
Private Ltd., rep. by Chief
Executive Officer, 11th Floor,
Brigade Towers, 139 Brigade
road, Bangalore-560 025.
O R D E R
A Rajesh, President.
The undisputed facts of the complainant’s case are as follows: The complainant is holding a health insurance policy issued by the opposite parties for his family for the period from 04-04-2010 to 03-04-2011. Initially he had availed the policy in the year 2008 and thereafter continued till date. The facts while so the complainant’s son Harith Krishna underwent treatment in AIMS, Kochi on 12-11-2010 for his intermittent abdominal pain. He had to pay a sum of Rs. 6,629/- for the treatment expenses. The complainant duly submitted claim application before the opposite party. They repudiated the claim stating that the claim is not admissible since the evaluations are not followed by active line of treatment under clause 4.8 of the policy. The complainant is entitled to get insurance amount together with compensation of Rs. 10,000/- with interest at the rate of 18% p.a. Hence this complaint.
2. In spite of service of notice from this Forum the opposite parties have not responded to for reasons of their own obviously no reasons coming hence forth. Proof affidavit has been filed by the complainant. Exts. A1 to A12 were marked on his side. Heard the learned counsel for the complainant.
3. The points that arose for consideration are
i. Whether the complainant is entitled to get insurance claim from the opposite parties for his treatment of his son named Harith Krishna?
ii.Compensation and costs of the proceedings.
4. Point No. i. The following points are not disputed for the conspicous absence of their own.
i. The complainant availed himself of Ext. A12 policy from the 1st opposite party for the period from 04-04-2010 to 03-04-2011.
ii. During the currency of the policy the complainant’s son Harith Krishna had to undergo treatment at AIMS Kochi on 12-11-2010.
iii. As per Ext. A3 medical certificate nothing abnormal has been diagnosed per se
iv. The complainant had to pay a sum of Rs. 6,629/- towards treatment expenses evidenced by Ext. A4.
v. The claim has been repudiated by the opposite party for the reasons stated in Ext. A11which reads as follows:
“Abdominal pain under evaluation –USG Abdomen relevant to the diagnosis shows normal results only –CT Abdomen is again undergone on 13/11/2010 for which reports are not provided – Other routine evaluations are also undergone following one day admission – Evaluation as such are not followed by any active line of treatment in which case the same is not payable under clause 4.8 of the policy – Hence this claim is not admissible.
5. Admittedly the tests were conducted for the purpose of diagnosis and the nature of treatment to be adopted on the patient. However the tests were found negative. However by abundant caution the doctor prescribed medicines as per Ext. A5 to A8 which go to show that active line of treatment was there in the case of the patient. The learned counsel for the complainant relied on a decision rendered by the Hon’ble Chhattisgarh SCDRC in Oriental Insurance Company Ltd. Vs. Shankarlal R. Patnani III (2005) CPJ 204 The Hon’ble Commission held that “ Every medical treatment is preceded by clinical or other examination of the patient and the discretion as to nature and the manner of such tests lies with the doctor”. Relying on and following the higher wisdom of the Hon’ble Chthishgarh State Commission we are only to bow to the same Despite notice the absence of the opposite parties is conspicuous and leaves this Forum with no room except to allow the claim of the complainant, legally and necessarily.
6. Points Nos. ii&iii. The lacrimal prayer of the complainant had not even primarily been listen to by the conspicuous absence of the opposite parties which goes to show that the prayer herein is not contested. An exemplary compensation of Rs. 2,000/- is awarded costs of Rs. 1,000/- is ordered.
7. In the result, we allow the complaint and direct as follows:
The 1st opposite party shall pay to the complainant insurance claim together with 12% interest p.a. from the date of repudiation till realization. The 1st opposite party shall also pay to the complainant Rs. 2,000/- towards compensation and Rs. 1,000/- as costs of the proceedings for the reasons stated above..
Pronounced in the open Forum on this the 30th day of September 2011.
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Exhibits
Complainant’s Exhibits;
Ext. A1 : Copy of Individual Health Insurance Policy -2009
A2 : MDCT Abdomen Contrast (Oral & I V) dt.
12/11/2010
A3 : Copy of discharge summary
A4 : Copy of In-Patient summary dt. 13/11/2010
A5 : Copy of pharmacy bill 18/11/2010
A6 : Copy of Material bill
A7 : Copy of pharmacy bill
A8 : Copy of In-patient advance
A9 : Medical certificate dt. 12-11-2010
A10 : Claim form
A11 : Repudiation letter
A12 : Brochure
Opposite party’s exhibits : Nil
