IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 21st day of October, 2013.
Present : Sri. Jacob Stephen (President)
Smt. K.P. Padmasree (Member)
C.C.No. 83/2013 (Filed on 21.06.2013)
Between:
1. Sivaraman. P.K.,
Palavilakizhakkethil,
Paranthal.P.O.,
Pin – 689 501,
Pandalam, Pathanamthitta Dist.
2. Anila Sivan, 7 years,
-do. –do.
(Minor rep. by her father 1st petitioner)
(By Adv. R. Gopikrishnan) ….. Complainant
And:
1. United India Insurance Co. Ltd.,
MICRO Office, Grace Plaza,
M.C. Road, Pandalam – 689 501.
Rep. by its officer in charge.
2. United India Insurance Co. Ltd.,
Regd. & Head Office, 24 Whites Road,
Chennai – 600 014,
Rep. by its officer in charge.
(By Adv.P.D. Varghese counsels for opp. 1 & 2)
3. M.D. India Health Care Services Pvt. Ltd.,
M.D. India House, 147/8 Near Kothrud-
Petrol Pump, Karve Statue Circle,
Kothrud, Pune – 411 038,
Rep. by its officer in charge. ….. Opposite parties
O R D E R
Sri. Jacob Stephen (President):
The complainants have filed this complaint against the opposite parties for getting a relief from the Forum.
2. The complainants case is that the 1st complainant and his family including the 2nd complainant are valid health insurance policy holders of the 1st opposite party vide policy No.101783/48/12/97/00002327 from 2010 onwards till the filing of this complaint. While so the 1st complainant had undergone treatment at NSS Medical Mission Hospital, Pandalam with complaints of LRTI from 23.02.2013 to 01.03.2013 and the 2nd complainant had undergone treatment at NSS Medical Mission Hospital, Pandalam for pneumonia from 09.01.2013 to 16.01.2013. The 1st complainant’s treatment expenses for the treatment was Rs.7,657/- and the 2nd complainant’s treatment expenses was Rs. 6,436/-. The 2nd complainant being a minor, the 1st complainant submitted their claim along with necessary documents including the original bills before the 1st opposite party. Thereafter, as per the direction of the 1st opposite party the complainant also submitted the cancelled cheque leaves to the 1st opposite party for disbursing both claims. Later, the opposite parties released an amount of Rs.2,613/- towards the claim of the 1st complainant ignoring the actual claim of Rs.7,657/-. At the same time, the claim of the 2nd complainant was not so far allowed by the opposite parties. The release of a reduced amount to the 1st complainant’s claim and the non-settlement of the 2nd complainant’s claim by the opposite parties is an unfair trade practice which caused financial loss and mental agony to the complainant and opposite parties are liable to the complainant for the same. Hence this complaint for the realization of the 1st complainant’s balance claim amount of Rs.5,044/- and for the realization of the 2nd complainant’s claim of Rs.6,436/- along with Rs.25,000/- as compensation and for realizing the cost of this proceedings.
3. 1st and 2nd opposite parties filed a common version with the following contentions. They admitted the policy in question and the claims submitted by the complainants. On getting the claim forms, this opposite party forwarded the claim documents to the 3rd opposite party who is the TPA of the answering opposite parties. On scrutiny of the 1st complainant’s claim they found that an amount of Rs.5,045/- is not payable as per the terms and conditions of the policy and the balance amount of Rs.2,613/- was already paid to the 1st complainant. At the same time on the scrutiny of the 2nd complainant’s claim, the 3rd opposite party found that some more documents are required for allowing the claim. So 3rd opposite party requested the 1st complainant to produce the original discharge card from the hospital and the original reports of investigation supporting diagnosis and also requested to furnish the ECS details such as the name of the account holder, name of bank and other details for transferring the claim amount. But so far the said details are not furnished by the complainants. In the circumstances, the claim of the 2nd complainant is still pending with them and it is not repudiated so far. Thus there is no deficiency in service from the part of the opposite parties and there is no cause of action to the complainant against the opposite parties. With the above contentions, 1st and 2nd opposite parties prays for the dismissal of the complaint.
4. 3rd opposite party is exparte.
5. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?
6. The evidence of this complaint consists of the oral deposition PW1, DW1 and Exts.A1 to A4 and B1 to B3. After closure of evidence, both sides were heard.
7. The Point:- The complainant’s allegation is that the 1st complainant’s medi claim for Rs.7,657/- was not allowed completely and they have released only Rs.2,613/- instead of allowing Rs.7,657/- and the 2nd complainant’s claim for Rs.6,436/- was not allowed so far in spite of submitting all relevant records for settling the medi claim policy. Since the complainants are valid policy holders, opposite parties are liable to allow the entire claim of the complainants and the opposite parties are liable to pay the same.
8. In order to prove the case of the complainants, 1st complainant filed a chief affidavit for himself and for and on behalf of the 2nd complainant in lieu of his chief examination along with 4 documents. On the basis of the proof affidavit, 1st complainant was examined as PW1 and the documents produced were marked as Exts.A1 to A4. Ext.A1 is the photocopy of discharge card dated 01.03.2013 issued from NSS Medical Mission Hospital, Pandalam in connection with the treatment of the 1st complainant from 23.02.2013 to 01.03.2013. Ext.A2 is the photocopy of medical certificate dated 05.03.2013 issued by the treated doctor in the prescribed format of the opposite party regarding the treatment of the 1st complainant. Ext.A3 is the photocopy of the discharge card dated 16.01.2013 issued from NSS Medical Mission Hospital, Pandalam in respect of the treatment of 2nd complainant from 09.01.2013 to 16.01.2013. Ext.A4 is the photocopy of medical certificate dated 21.01.2013 issued by the treated doctor in the prescribed format of the opposite parties in respect of the treatment of the 2nd complainant.
9. On the other hand, the contention of the 1st opposite party is that on receipt of the claims of the complainants they have forwarded the same to the 3rd opposite party for processing. After processing 3rd opposite party allowed Rs.2,613/- to the 1st complainant as he is entitled only to get this amount as per the terms and conditions of the policy, though his claim was Rs.7,657/- and the 2nd complainant’s claim is till pending as the claimants has not furnished the required documents in spite of the request for the same by the 3rd opposite party. They also submitted that they are ready and willing to allow the 2nd complainant’s claim if they comply the directions of the 3rd opposite party. Thus they argued that they have not committed any deficiency in service.
10. In order to prove the contentions of the 1st and 2nd opposite parties, The Ernakulam Branch Manager of the 3rd opposite party was examined as a witness as DW1 and 3 documents were marked as Exts.B1 to B3 in their favour. Ext.B1 is the copy of the letter issued by the 3rd opposite party in the name of the 2nd complainant calling her to produce certain records for processing her claim. Ext.B2 is the terms and conditions of the individual health insurance policy of the opposite parties. Ext.B3 is the copy of the calculation sheet prepared by the 3rd opposite party showing the allowable and non allowable amounts in the treatment of the 1st complainant which shows that the 1st complainant is entitled to get only an amount of Rs.2,613/-.
11. On the basis of the contentions and arguments of the parties and on the basis of the allowable materials on record, it is found that the complainants are medi claim policy holders of the opposite parties and the complainants had undergone treatment during the validity of the policy and they have submitted their claim for their treatment expenses before the opposite parties and the opposite parties partly allowed the1st complainants claim and the 2nd complainant’s claim has not been allowed so far and it is still pending for want of necessary documents and not repudiated so far. According to the complainants they are entitled to get the entire treatment expenses. But according to the opposite parties, as per the terms and conditions of the policy the 1st complainant is entitled only to get Rs.2,613/- and the said amount was already given to him. The 2nd complainant’s claim is not yet processed as they have not furnished the necessary documents so far in spite of their request to the 1st complainant for the same and they are ready and willing to allow the claim of the 2nd and complainant as per the terms and conditions of the policy if they are prepared to comply the directions of the 3rd opposite party. The complainants’ argument is that he had submitted the originals of the entire documents to the 1st opposite party for processing the claims. But the argument of the opposite parties is that they have not received the entire original documents which are required for the proper processing of the claims. But it is pertinent to note that the complainant has not adduced any evidence to show that he had submitted the required documents in original to the opposite parties. But he admitted in cross-examination that he had received a letter from 3rd opposite party calling to produce certain documents. The said letter is marked as Ext.B1 in this case. Complainant also deposed before this Forum that on getting Ext.B1 he had submitted all the original documents before opposite parties. The said deposition is totally against his pleading that he had submitted all documents before opposite parties along with the claim form. But he had also failed to adduce any evidence to show that he had submitted the records as per Ext.B1. Thus it is clear that opposite parties are not in receipt of necessary documents required for processing the claim of the 2nd complainant. At the same time opposite parties submitted that they are ready and willing to settle the claim of the 2nd complainant on getting the required documents.
12. Further with regard to the 1st complainant’s balance claim, opposite parties contention is that as per the terms and conditions of the policy he is entitled to get Rs.2,613/-. But how can this Forum interfere in this dispute relying on Ext.A1 and A2 as the said documents are insufficient to prove the complainants claim. Complainant has not produced the medical bills and the treatment bills. In the absence of such evidences before this Forum, this Forum cannot blame the opposite parties for the settlement of a reduced amount. However, complainants are entitled to get his genuine claim if he is prepared to convince opposite parties about the genuineness of his balance claim. In the circumstances, this complaint is disposed with the following directions:
(i) Opposite parties are directed to reconsider the 1st complainant’s claim if the 1st complainant submits any more documents supporting his claim.
(ii) Opposite parties are further directed to allow the 2nd complainant’s claim on getting either the copy or originals of the required documents supporting the 2nd complainant’s claim.
(iii) Parties are directed to comply this order within 15 days from the date of receipt of this order.
(iv) No order for cost and compensation.
Declared in the Open Forum on this the 21st day of October, 2013.
(Sd/-)
Jacob Stephen,
(President)
Smt. K.P. Padmasree (Member) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : P.K. Sivaraman
Exhibits marked on the side of the complainant:
A1 : Photocopy of discharge card dated 01.03.2013 issued from NSS
Medical Mission Hospital, Pandalam.
A2 : Photocopy of medical certificate dated 05.03.2013 issued by the
treated doctor in the format of the opposite party.
A3 : Photocopy of the discharge card dated 16.01.2013 issued by NSS
Medical Mission Hospital, Pandalam.
A4 : Photocopy of medical certificate dated 21.01.2013 issued by the
treated doctor in the prescribed format of the opposite party.
Witness examined on the side of the complainant:
DW1 : Sreejith Rajan
Exhibits marked on the side of the complainant:
B1 : Copy of a letter issued by the 3rd opposite party in the name of the
2nd complainant.
B2 : Terms and conditions of the individual health insurance policy of the
opposite parties.
B3 : Copy of the calculation sheet prepared by the 3rd opposite party.
(By Order)
(Sd/-)
Senior Superintendent.
Copy to:- (1) Sivaraman. P.K., Palavilakizhakkethil, Paranthal.P.O.,
Pin – 689 501, Pandalam, Pathanamthitta Dist.
(2) Officer in Charge, United India Insurance Co. Ltd.,
MICRO Office, Grace Plaza, M.C. Road,
Pandalam – 689 501.
(3) Officer in Charge, United India Insurance Co. Ltd., Regd. &
Head Office, 24 Whites Road, Chennai – 600 014.
(4) Officer in Charge, M.D. India Health Care Services Pvt. Ltd.,
M.D. India House, 147/8 Near Kothrud Petrol Pump, Karve
Statue Circle, Kothrud, Pune – 411 038,
(5) The Stock File.
