O R D E R

By Dr.K.Radhakrishnan Nair , Member :

          Facts : The case of the complainant is that he was insured with the opposite party under Health wise policy (gold scheme).  A health card bearing the No.282530004026 was also issued.  As promised, on producing the above card to T.P.A.(Third Party Administrator) cashless facility will be provided from the network hospitals. Complainant was admitted on 23/5/10 under OPNo.467514 in Thrissur Aswini hospital and after treatment discharged on 27/5/2010.  Cashless facility was allowed up to 27/5/2010 and remaining bill amount was not paid by the opposite party.  In order to get the amount n reimbursement basis complainant was instructed to submit l the bills to the TPA by the hospital.  On discharge the balance amount had to be paid by the complainant selling the gold ornaments of his wife for a less price suffering great loss.  Complainant alleges that non-settlement of the complete amount of treatment expenses to the tune of Rs.16,520.30 as claimed on 26/6/2010 before the 2^nd opposite party amounts to deficiency in service as well as unfair trade practice .  Complainant had to undergo mental agony and serious hardships.  Therefore complaint may be allowed directing the opposite party to pay rs.16,520.30 with 12% interest from 23/5/10 and Rs.75,000/- towards compensation and costs.

          2.Case was admitted.  Ordered notice to opposite parties.  2^nd to 6^th opposite parties appeared before the Forum through counsel and filed their version.  Besides categorical denial of majority of allegations, opposite parties avers that both claims submitted by the complainant were settled.  Claim No.5054/681 was settled for Rs.22,504/- and the subsequent claim was  settled for Rs.5,200/- towards full and final settlement.  A sum of Rs.11,500/- was disallowed in the absence of supporting bills as well as not payable under the policy.   There is no deficiency in service or unfair trade practice.  Complaint may therefore be dismissed with costs.

          3.Then the case posted for evidence.  The following points are considered for its final disposal.

1) Is there any deficiency in service or unfair trade practice on the part of opposite parties?

2)If yes, what are the reliefs and costs?

          4.Both parties filed proof affidavits and complainant produced following documents and marked as Exts.P1to P6.  Ext.P1 – policy schedule, Ext.P2 – claim form, Ext.P3 – Receipt of courier,Ext.P4- Power of Attorney,Ext.P5 – SBI statement, Ext.P6 series South Indian Bank statement(1,2,3). Opposite parties produced three documents and marked as Exts.R1 to R3.  Ext.R1- policy schedule and terms and conditions, Ext.R2 – settlementadvice,Ext.R3 – approved amount on reimbursement basis.  Oral evidence was also tendered.  Complainant’s power of attorney holder was examined.  His deposition is marked as PW1. Both filed argument notes and the matter was heard in detail.

          5. We have examined proof affidavit filed by complainant and documents and deposition and are convinced that there is deficiency in service on the part of opposite parties.  Proof affidavit filed by the complainant, it is affirmed that he has not received any such amount said to have been sent through a cheque of HDFC. Proof affidavit filed by the 2^nd OP affirms that such a cheque is given. No documents are produced by the OP to support their plea. Whereas documents produced by the complainant such as Ext.P6 banks statements would convince us that they have not received the same.  In the absence of any contra evidence by the opposite party, to show the receipt of the amount towards full satisfaction and without any protest, we the Forum has no other alternative but to give a verdict in favour of the complainant and we find that there is deficiency in service.

          6.Relief and cost : We direct the opposite parties to pay Rs.5,200/- (Rupees Five thousand and two hundred only) the eligible amount said to have been settled with 12%interest from 23/5/10 and Rs.5,000/- (Rupees Five thousand only) towards cost to the complainant within 30 days from the receipt of this order.  Complaint allowed accordingly.

            Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Commission  this the  17^th   day  of April  2021.

Sd/-                      Sd/-                                          Sd/-

Sreeja.S                Dr.K.Radhakrishnan Nair         C.T.Sabu                       

Member                Member                                    President                           

                                      Appendix

Complainant’s Exhibits

Ext.P1 – policy schedule, Ext.P2 – claim form, Ext.P3 – Receipt of courier,Ext.P4- Power of Attorney,Ext.P5 – SBI statement, Ext.P6 series South Indian Bank statement(1,2,3)   

Complainant’s witness  

PW1 - Krishnakumar

Opposite Parties Exhibits        

Ext.R1- policy schedule and terms and conditions, Ext.R2 – settlementadvice,Ext.R3 – approved amount on reimbursement basis.                                                                                                Id/-

                                                                                      Member