Kerala

StateCommission

A/16/770

ORIENTAL INSURANCE COMPANY - Complainant(s)

Versus

YOOSUF - Opp.Party(s)

B RAVIKUMAR

03 Oct 2019

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION SISUVIHARLANE VAZHUTHACADU THIRUVANANTHAPURAM

 

APPEAL NUMBER 770/16

JUDGMENT DATED : 03.10.2019

 

(Appeal filed against the order in CC.No.378/2014

 on the file of CDRF, Malappuram )

PRESENT

SRI.T.S.P. MOOSATH                       : JUDICIAL MEMBER

SRI.RANJIT. R                                  : MEMBER

 

APPELLANTS

 

The Manager, M/s.Oriental Insurance Company Ltd, Kairali Tower, Palakkad Road, Mele Pattambi.P.O, Palakkad,

Rep.by is Deputy Manager, T.P.Hub, Do 11, Ulloor, Thiruvananthapuram

 

                (By Adv.Varkala B Ravikumar)

 

                                VS

RESPONDENTS

1. Yoosuf.P, S/o.Hamzakuttyj Pallat House,

Elad.P.O, Elamkulam, Malappuram District

 

2. The Managing Director, M/s.Shifa Medic Are Trust,

Al-Shifa Hospital Complex, Ootty Road, Perinthalmanna

 

(R1 by Adv.Sri.N.G.Mahesh)

JUDGMENT

SRI.T.S.P.MOOSATH                : JUDICIAL MEMBER

                     The first opposite party in CC.No.378/2015 of the Consumer Disputes Redressal Forum, Malappuram in short the district forum has filed the appeal against the order passed by the district forum by which they were directed to payRs 70,000/-, The amount spent by the complainant for treatment and hospitalization together with Rs 25,000/- as compensation for mental agony and Rs 5000/- as cost.

 

                           2.  According to the complainant he had taken a personal Accident Insurance Policy known as Nagarik Suraksha Individual Policy from the opposite party on 16.05.2014 for the period from 16.05.2014 to 15.05.2015 with a total premium of Rs 303/-. The policy with the conditions was issued to the complainant on 16.05.2014 itself. It is stated by the complainant that on 10.02.2015 he sustained an injury by a twig of a tree and he was treated in a hospital on Cheraplassery and since he could not recover he was admitted in EMS Hospital, Perinthalmanna on 14.02.2015. He claims to have spent Rs 70,000/- for his treatment. He submitted the bills to the opposite party for reimbursement. But the opposite party repudiated the claim, since the hospitalization was due to Diabetic Mellitus. Hence the complainant has filed the complaint against the opposite parties alleging deficiency of service on the part of the opposite parties. The opposite parties filed version contending that the treatment of the complainant was for diabetics mellitus which is not covered by the policy and it was pre - existing one. As per the policy hospital expenses are limited to Rs 40,000/-. The treatment bills produced by the complainant are not correct and the complainant is not entitled to get any amount. Hence the repudiation of the complainant is valid and there is no deficiency in service on the part of the opposite parties and the complaint is to be dismissed.

 

                     3.        The complainant filed affidavit and Exts.A1 to A4 series were marked on his side. The first opposite party filed affidavit and Exts.B1 to B4 were marked on the side of the opposite parties. Considering the evidence adduced by the parties and hearing both siders the district forum has passed the impugned order. Aggrieved by the order passed by the district forum the opposite parties have preferred the present appeal.

 

               4.      Heard both sides. Perused the records.

 

            5. There is no dispute to the fact that the complainant had taken a Nagarik Suraksha Individual Policy from the opposite parties and it was valid for the period from 16.05.2014 to 15.05.2015. Ext.B1 is the policy and Ext.A2 is the copy of the same. The policy provides insurance coverage for the personal Accident and offers reimbursement of hospital expenses. It is the case of the complainant that on 10.02.2015 he sustained a wound by a twig of a tree and he was admitted in the hospital at Cheruplassery. Since he could not recover from the ailment he was shifted to EMS Hospital perinthalmanna on 14.02.2015 and after treatment he was discharged on 18.02.2015. According to the complainant he had spent Rs 70,000/- for his treatment. The complainant preferred a claim before the first opposite party and it was repudiated by them contending that the treatment was for diabetic mellitus. The district forum found that the injury sustained by the complainant was due to an accident and hence the repudiation of the claim of the complainant by the opposite parties is deficiency in service.

 

                    6. As submitted by the counsel for the appellant the complainant has not produced any document regarding his alleged treatment in the hospital at Cheruplassery. It is the case of the complainant that after the treatment in the hospital at Cherplassery  he was shifted to EMS Hospital, Perinthalmanna on 14.02.2015 and he had undergone impatient treatment there and he was discharged from there on 18.02.2015. Ext.A1 is the copy of the discharge summary from EMS Hospital, Perinthalmann wherein it is stated that the complainant was treated for abscess with discharging pus, right leg. In Ext.A1 is the cause of the ailment of the complainant is not stated. Ext.A3 is the copy of the discharge summary issued from the Jubilee Mission Hospital, Thrissur. from which it can be seen that the complainant had undergone impatient treatment in that hospital from 04.03.2015 to 11.03.2015. In Ext.A3 it is stated that the complainant approached the hospital with non healing wound over right leg following thorn prick. It is true that in the compliant the complainant has not stated about his treatment in the Jubilee Mission Hospital, Thrissur. That may be an omission. From Ext.A3 it can be seen that the treatment of the complainant was for the injury caused by thorn prick and it was not caused by diabetic mellitus. As found by the district forum it is true that the complainant was stricken with diabetic mellitus and that might have been aggravated the condition of the injury sustained by him. But at any rate it cannot be concluded that the injury sustained by the complainant by thorn prick is an injury caused by the Diabetic mellitus. The plain meaning of the word‘accident’ is something that happens unexpectedly and is not planned in advance and thus an injury caused unexpectedly by any means can be considered as an injury caused by an accident. Considering all these facts the district forum found that the rejection of the claim of the complainant by the opposite parties is deficiency in service on the part of the opposite parties and they are liable to pay the treatment expenses of the complainant and compensation to him. We consider that there is no ground / reason to interfere with the finding of the district forum.

 

                      7.       The district forum directed the opposite parties to pay Rs 70,000/- as the amount spent by the complainant for treatment and for hospitalization. The counsel for the appellants pointed out that as per the terms and conditions of the policy but the maximum amount that can be claimed as the treatment expenses is Rs 40,000/- and the complainant has not produced bills in support of his claim that he had spent Rs 70,000/- for treatment and hospitalization and without considering these aspects the district forum directed the opposite party to pay Rs 70,000/- to the complainant,as claimed by him. On a perusal of the order passed by the district forum it can beseen that there is some basis  in the submission made by the counsel for the appellant with the district forum has not considered these aspects. The complainant can claim benefits only as per the terms and conditions of the Insurance Policy. As per section II of Ext.B1 policy in the case of hospital treatment for the injury arising out of an accident the liability of the insurance company shall not exceed the sum specified in the schedule of the policy. As per the schedule of the policy the maximum amount that can be granted for hospitalization and treatment expenses is Rs 40,000/-. So the maximum amount that can be claimed by the complainant for treatment and hospital expenses is Rs 40,000/-.

 

                     8.        Complainant has not produced any document regarding his alleged treatment in the hospital at Cheruplassery. He has not produced any bills towards the treatment expenses, for his treatment at EMS Memorial Hospital, Perinthalmanna. Ext.A4 series are the bills regarding the treatment of the complainant at Jubilee Mission Hospital, Thrissur. The total amount covered by Ext.A4 series bills is around Rs 19,000/-. Considering all these facts, it can be seen that the amount ordered to be paid by the opposite parties to the complainant by the district forum is to be reduced / modified. We consider that the amount ordered by the district forum to be paid by the opposite parties to the complainant towards the treatment and hospital expenses to be reduced and modified to Rs 20,000/-. The district forum directed the opposite parties to pay Rs 25,000/- as compensation for mental agony. Considering the evidence, facts and circumstances we find just and reasonable to reduce the compensation ordered by the district forum to Rs 10,000/-. The cost of Rs 5000/- ordered by the district forum is just and reasonable and no interference is called for regarding that. The direction passed by the district forum to pay interest at the rate of 12% per annum from the date of order if the opposite parties fail to pay the amount ordered within 30 days from the date of receipt of the copy of the order is set aside.

 

                    In the result, the appeal is partly allowed. The order passed by the district forum is modified as follows. The opposite parties are directed to pay Rs 20,000/- as towards the amount spent by the complainant for treatment and hospitalization together with compensation of Rs 10,000/- and cost of Rs 5000/- to the complainant.

 

                    At the time of filing of the appeal the appellant has deposited Rs 25,000/- . The first respondent / complainant is permitted to obtain release of the said amount by filing proper application, to be adjusted / credited towards the amount ordered as above.

 

                     Opposite parties shall pay the balance amount to the complainant within one month from the date of the receipt of the copy of the order, failing which they shall pay interest at the rate of 10% per annum for the said amount, from the date of order, till realization.

 

 

T.S.P. MOOSATH             : JUDICIAL MEMBER

 

 

RANJIT.R                         : MEMBER

 

 

 

 

 

Be/

 

 

 

 

 

 

 

 

 

 

 

.KERALA STATE

CONSUMER DISPUTES

REDRESSAL COMMISSION

SISUVIHARLANE

VAZHUTHACADU

THIRUVANANTHAPURAM

 

APPEAL NUMBER 770/16

JUDGMENT DATED : 03.10.2019