DATE OF FILING : 12.1.2017

IN THE CONSUMER DISPUTES  REDRESSAL FORUM, IDUKKI

Dated this the  28th  day of  March,  2019

Present :

SRI. S. GOPAKUMAR PRESIDENT

SMT. ASAMOL. P    MEMBER

CC NO.6/2017

Between

Complainant       :   Sabu P.I.,

Poovankal House,    

Manakkadu P.O.,

Thodupuzha, Idukki.

(By Adv:  K.M. Sanu)

And

Opposite Parties                                          :   1.  The Manager,

       United India Insurance Co. Ltd.,

       SV Tower, Neyyattinkara,

       Thiruvananthapuram – 695 121.

  2.  The Manager,

       United India Insurance Co. Ltd.,

       Thodupuzha Branch, 

       Thodupuzha P.O., Idukki.

       (Both by Adv:  Sony George)

  3.  The Manager, 

       Vidal Health TPA Pvt. Ltd.,

       Mareena Building, M.G. Road,

       Ernakulam – 682 016. 

 

O R D E R

 

SRI. S. GOPAKUMAR, PRESIDENT

Case of the complainant is that,

        Complainant is a reporter of Desabhimani daily.  He joined in the health Insurance Scheme conducted by the Kerala Union of Working Journalists and United India Insurance Company, Jointly, for the welfare of the working journalists in the name KPP Arogya Pariraksha Padhathi.  It is a group insurance scheme and it covers the mediclaim of the family of the policy holder.  The complainant joined in this scheme from 2015 April onwards and he renewed it by paying Rs.3000/- aS premium for the period from 2016 April to 2019 March.  The policy coverage is Rs.1,25,000/- including the wife and 2 children of the policy holder.               (cont...2)

-  2  -

        While so, when the policy was in active, the son of the complainant, Abhishek was admitted in MOSC, Kolenchery for the complaint of kidney stone and treated there as in patient from 30.5.2016 to 2.6.2016.  He spent an amount of Rs.29,700/- for treatment alone.  Immediately after the discharge of the patient, the complainant submitted claim application before the 1st opposite party through the General Secretary, Kerala Working Journalists, along with relevant treatment records and bills.  But the 3rd opposite party repudiated the claim on the reason that there has been a delay in lodging the claim.  The complainant further stated that he submitted the claim application within time, but opposite party raised the objection in sanctioning the claim only to help the other opposite parties.  The act of the opposite parties amounts to gross deficiency in service as well as unfair trade practice.  Hence complainant filed this petition for allowing the reliefs such as to direct the opposite parties to sanction the mediclaim along with interest at the rate of 18% from 2.6.2016 and further direct them to pay compensation and cost.

        Upon notice, opposite parties entered appearance and opposite parties 1 and 2 filed reply version.  In their version, opposite parties 1 and 2 contended that, they are not aware of some facts stated by the complainant and after the treatment, the complainant has not submitted all the relevant documents within the time and also the complainant did not give any proper explanations for the same.  The opposite parties further contended that if any application for claim is submitted by the complainant to the 3rd opposite party, it might be improper and delayed.  Therefore the 3rd opposite party has send notice to the complainant.  If  any amount is failed to issue to the complainant, it was due to  the  dereliction of duty from the complainant.  Hence the complainant is not liable to get any compensation from the opposite parties.

        Evidence adduced by the complainant by way of documents.  Complainant produced letter from the 3rd opposite party dated 22.10.2016, 

(cont...3)

-  3  -

copy of claim form dated 5.7.2016, copy of treatment records and discharge summary of Abhishek S, which are marked as Exts.P1 to P4 respectively. 

        From the defence side, no oral or documentarily evidence adduced.

        Heard both sides.      

        The points that arose for consideration is whether there is any deficiency in service from the part of opposite parties and if so, for what relief the complainant is entitled to ?

        The POINT :-  We had heard the counsels for both parties and gone through the evidence on records.  It is admitted fact that at the time of admission of the son of the complainant, the policy was in force and is valid.  The treatment records shows that, the patient was admitted and treated MOSC Medical College from 30.5.2016 to 2.6.2016 for the complaint of  Bilateral Renal Calculi (Right 1 cm left 2 cm) and an amount of Rs.23,700/- was spent for treatment alone.  This matter was not denied by the opposite parties.  They denied the claim only on the reason of delay in submitting claim application. For solving this issue, we had gone through Ext.P2, copy of claim form.  On perusing this, we convinced that the claim form is prepared on 5.7.2016 and is submitted through the General Secretary, Kerala Pathra Pravarthaka Aryogya Pariraksha Padhathi and the complainant performed his part without any delay.  If any delay is caused from the part of the above said General Secretary.  Complainant is not at all liable for that.  

        On the basis of the above discussion, the Forum is of a considered view that, delay in sanctioning the claim, on the basis of some lame excuses is a clear violation of the legal right of the complainant and it amounts to gross deficiency in service as well as unfair trade practice.  

        Under the above circumstances, complaint allowed.  The Forum  directs opposite parties 1 to 3 to pay an amount of Rs.27800/- jointly to the complainant  being the treatment expenses of  his  son  Abhishek,  along

             (cont...4)

-  4  -

with 12% interest from 2.6.2016 till the date of payment, and  to pay Rs.5000/- as litigation cost, jointly, within  30 days from the date of receipt of a copy of this order.

              Pronounced in the Open Forum on this the 28th  day of  March, 2019

  Sd/- 

   SRI. S. GOPAKUMAR, PRESIDENT

 

Sd/- 

         SMT. ASAMOL. P., MEMBER

 

 

 

APPENDIX

Depositions :

Nil.

Exhibits :

On the side of the Complainant :

Ext.P1            -  letter from the 3rd opposite party dated 22.10.2016.

Ext.P2            -  copy of claim form dated 5.7.2016, 

Ext.P3            - copy of treatment records

Ext.P4            - discharge summary of Abhishek S.

On the side of the Opposite Party :

Nil.

 

 

 

 

 

 

     Forwarded by Order,

 

 

 

             SENIOR SUPERINTENDENT