BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 07/03/2013

Date of Order : 31/01/2014

Present :-

Shri. A. Rajesh, President.

Shri. Sheen Jose, Member.

Smt. V.K. Beena Kumari, Member.

C.C. No. 181/2013

Between

And

O R D E R

V.K. Beena Kumari, Member.

1. The facts leading to this complaint are as follows :

The complainant had taken a medical insurance policy by name “Health Care Plus Policy” from the 1^st opposite party by paying annual premium of Rs. 2,975/-. The policy number issued to the complainant was 2,817/5173 dated 28-10-2011. The policy covered insurance of the complainant and his wife for Rs. 1 lakh. The policy was renewed by paying premium of Rs. 6,847/- raising the sum assured to Rs. 2,50,000/-. On 15-10-2012, the complainant's wife was admitted to Lakeshore hospital for heart treatment and was discharged after treatment on 20-10-2012. An amount of Rs. 2,24,013/- was spent towards her treatment charges, which included cost of medicines also. On 13-11-2012, medical claim form in the prescribed proforma together with medical bills was submitted to the opposite party and on 14-11-2012, the opposite party issued a letter to the complainant asking for 4 documents out of which 3 documents were submitted by the complainant on 27-11-2012, but the indoor case papers were not submitted to the opposite parties since the hospital had not issued the same to the complainant. On 05-12-2012, the opposite party again asked for the ICP documents. The complainant on 17-12-2012 had informed, as directed by the doctor, the opposite party to verify the said papers directly in the hospital. The complainant also submitted doctor's letter to the opposite party. But the opposite party again and again sent letters to the complainant asking for Indoor Case Papers (ICP). The complainant sent a registered notice to the opposite party asking to settle the claim on 29-01-2013 acknowledged by the opposite party. The mediclaim has not been settled so far. Hence this complaint was field before this Forum seeking direction to the opposite parties to pay the policy amount of Rs. 1,00,000/- with interest @ 10% from the date of submission of the claim and to pay Rs. 10,000/- towards compensation for the inconveniences suffered by the complainant.

2. The version filed by the opposite parties 1 to 3 is as follows :-

The opposite parties 1 to 3 in their version contended that the complaint is not maintainable either in law or on facts of the case, that the opposite party is liable to compensate only in accordance of the terms and conditions of the policy, that the complainant is under contract of insurance bound to produce all the documents necessary for processing the claim to the opposite parties, that there is no deficiency in service on the part of the opposite parties, that the opposite parties are willing to process the claim of the complainant on production of Indoor Case Papers in possession of the 4^th opposite party hospital, that the claim could not be processed for want of the Indoor Case Papers. It is prayed that the contentions raised by the opposite parties 1 to 3 may be accepted.

3. No oral evidence for the complainant. The documentary evidence produced by the complainant were marked as Exts. A1 to A11. Neither oral nor documentary evidence produced by the opposite parties 1 to 3. The ICP submitted by the 4^th opposite party was marked as Ext. X1. Heard the complainant and counsel for the opposite parties 1 to 3.

4. The points to be decided in this case are as follows :-

1. Whether the complaint filed is maintainable or not?

2. Whether the complainant is entitled to the mediclaim from the opposite parties?

3. Whether the complainant is entitled to get compensation or not?

5. Point Nos. i. and ii. :- The opposite parties 1 to 3 have admitted in their version that the complainant is entitled to get the policy amount only in accordance with the terms and conditions of the policy taken by the complainant and that the complainant is under the contract of insurance bound to produce all documents necessary for processing the claim to the opposite parties. The complainant submitted 3 documents to the opposite parties except the Indoor Case Papers which was in possession of the 4^th opposite party hospital. The opposite parties 1 to 3 have no case that the complainant had not taken any policy from them. Therefore, we find that this complaint is maintainable. Further, the opposite parties 1 to 3 in their version stated vide paragraph 7 that they are willing to process the claim of the complainant on production of the Indoor Case Papers/sheets in possession of the 4^th opposite party hospital. Thus, the only contention of the opposite parties 1 to 3 is that they could not process the claim of the complainant for want of Indoor Case Papers of the 4^th opposite party hospital. There is no objection to the other averments of the complainant. This Forum has summoned the case records of Aisha Shymalan, the wife of the complainant from the 4^th opposite party hospital and the Indoor Case Papers were submitted to this Forum by the 4^th opposite party hospital marked as Ext. X1 with 78 pages. Admittedly, the opposite parties have not yet processed the claim application of the complainant for want of Indoor Case Papers of the 4^th opposite party hospital. Therefore, the opposite parties are directed to process the mediclaim of the complainant on the basis of Ext. X1 and to issue settlement papers in accordance with the terms and conditions of the policy taken by the complainant.

6. Point No. iii. :- The complainant sought for an order from this Forum to grant Rs. 10,000/- towards compensation for the difficulties suffered by him. We are not inclined grant any compensation, since there is no deficiency in service on the part of the opposite parties and the opposite parties have not yet processed the mediclaim of the complainant, for want of treatment records from the 4^th opposite party hospital. After settlement of the mediclaim, the complainant may approach this Forum, if he is still aggrieved. We also find that it is premature to order any grant of compensation at this juncture. Therefore, no order issued granting compensation or costs of the proceedings.

7. In the result, we partly allow the complaint and direct as follows :-

1. The complainant is directed to take steps to produce a copy of the Indoor Case Papers (ICP) to the opposite parties 1 to 3 so as to enable them to process the insurance claim application in accordance with the terms and conditions of the policy.

2. The opposite parties 1 to 3 shall on receipt of the Indoor Case Papers process the mediclaim of the complainant in accordance with the terms and conditions of the policy within 60 days from the receipt of a copy of the ICP from the complainant.

Pronounced in the open Forum on this the 31^st day of January 2014.

Sd/- V.K. Beena Kumari, Member.

Sd/- A. Rajesh, President.

Sd/- Sheen Jose, Member.

Forwarded/By order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

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