BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD, THIRUVANANTHAPURAM.

PRESENT

SRI. G. SIVAPRASAD : PRESIDENT

SMT. BEENAKUMARI. A : MEMBER

SMT. S.K.SREELA : MEMBER

C.C. No. 111/2010 Filed on 09.04.2010

Dated : 31.10.2011

Complainant :

K.S. Suresh Chandran Nair, Aswathy, Ramapuram, Thannimoodu P.O, Pin-695 123.

(By adv. V.N. Gopalakrishnan Nair)

Opposite parties :

1. Medi Assist Indian TPA Pvt. Ltd., 5^th Floor, Oricon House 12, Kalkushroo, Duhash Marg, Kalagoda, Mumbai – 400 023.

    

2. Life Insurance Corporation of India, Neyyattinkara Branch, Neyyattinkara P.O.

(By adv. M.R. Bindu)

This O.P having been heard on 04.10.2011, the Forum on 31.10.2011 delivered the following:

ORDER

SMT. BEENAKUMARI.A: MEMBER

Facts of the case are as follows: The complainant is an employee working as Chief Life Insurance Advisor under the 2^nd opposite party. The 2^nd opposite party is having an insurance with the 1^st opposite party for their employees. And the policy No. is 120300/34/07/12/00000324. Due to severe knee joint pain, Rt shoulder pain and sneezing the complainant was admitted and underwent Ayurveda treatment at Pankajakasthuri Ayurveda Medical College Hospital, Thiruvananthapuram during 03.07.2008 to 16.07.2008. On 16.07.2008 he was discharged from the hospital after settling full amount from his pocket. On 23.07.2008 the complainant had submitted all the documents of treatment to the 2^nd opposite party for submitting it before the 1^st opposite party for refunding the amount spent for treatment. There was no response about the refunding of the amount from the 1^st opposite party for about 5 months and then the complainant called the 1^st opposite party over telephone and enquired about the repayment, they told that the refund would be made within another one month. Believing the words of the 1^st opposite party the complainant waited for another 2 more months. Thereafter the opposite party informed the complainant that since the treatment was Ayurveda treatment, he cannot claim the money from the 1^st opposite party. Thereafter the complainant had sent two notices to the opposite parties. But there was no reply from the side of opposite parties. Thereafter the complainant sent a registered notice to the opposite party and a reply was received stating that the 1^st opposite party will repay the amount only if the treatment was conducted in any Government Ayurveda Hospital. Since the complainant had underwent treatment in a private Ayurveda Hospital he is not entitled to get the treatment amount refunded. The complainant further submitted that on 26.07.2007 to 08.08.2007 he was admitted in the same hospital and at that time opposite party refunded the hospital bill through a cheque No. 126441. Hence the complainant submitted that he is entitled to get the treatment amount of Rs. 19,381/- from the opposite party along with interest and compensation.

The 1^st opposite party in this case accepted notice of this complaint from this Forum, but not turned up to contest the claim. 2^nd opposite party LIC of India filed version. In the version they stated that the 2^nd opposite party is having an insurance with the 1^st opposite party for their employees. The 2^nd opposite party has no other role except collecting the documents from the employees and sending it to the 1^st opposite party. It is the 1^st opposite party who is bound to pay the claims if any to the policy holders. No amount is claimed by the complainant against the 2^nd opposite party. The 2^nd opposite party is an unnecessary party to the proceedings. The complainant produced the treatment details on 23.03.2008 before the 2^nd opposite party and that was forwarded to M/s Medi Assist India Pvt. Ltd. Bangalore on the same day itself. The complainant again submitted the document on 25.08.2009 for re-submission that was also submitted. So there is no deficiency of service on the part of 2^nd opposite party.

The points that would arise for consideration are:-

1. Whether there has been deficiency in service and unfair trade practice occurred from the side of opposite parties?

2. Whether the complainant is entitled to get the reliefs and costs sought for ?

    

Points (i) & (ii):- The complainant in this case is a policy holder of 1^st opposite party. During policy period he had undergone Ayurvedic treatment in Pankajakasthuri Medical College for knee joint pain. The hospital bills were paid by the complainant at the time of discharge on 16.07.2008. Thereafter he submitted the treatment details to the 1^st opposite party for getting refund of the amount. But the opposite party rejected his claim on the ground that as per policy conditions, Ayurvedic treatment conducted in Government hospital only be payable under this policy. But the complainant argued that the opposite party had earlier refunded the expenses for the treatment in the same hospital to the complainant by cheque No. 12644. To prove his contentions the complainant has filed proof affidavit in lieu of chief examination and he was examined as PW1. From his side 5 documents were marked as Exts. P1 to P5. Since there was no cross examination from the side of opposite parties, the affidavit filed by the complainant stands unchallenged. Ext. P1 series are the copies of letters issued by the complainant to the 1^st opposite party requesting the claim amount. Ext. P2 is the copy of registered letter dated 16.09.2009. Ext. P3 is the claim repudiation letter dated 02.11.2009. In this letter the opposite party stated that “As per policy terms and conditions, Ayurvedic treatment charges are payable provided the treatment is taken in government hospital. On perusal of the claim documents submitted, it is found that claimant has not taken treatment in government hospital”. In this case the complainant and opposite party have not produced the policy before us. If as per the policy conditions the claim is not payable, it is the duty of the 1^st opposite party to produce the policy copy before us. In the absence of the same, we find that the opposite party has failed to corroborate their reason for repudiation and justify their act. Ext. P4 is the copy of the hospital bill dated 16.07.2008. As per this document the total amount is seen as Rs. 19,381/-. Ext. P5 is the copy of hospital bill for an amount of Rs. 13,287/-. The complainant states that the opposite party had paid this bill amount earlier on the basis of this policy.

In this case there is no dispute regarding the policy. Only dispute is that as per the opposite party the treatment underwent by the complainant in a private Ayurvedic hospital is not payable under the policy. The complainant states that in an earlier occasion the opposite party had paid the treatment amount to the complainant for treatment in the same hospital. In this case neither the complainant nor the opposite party produced the policy copy. Since the 1^st opposite party remained ex-parte, from the available documents before us we find that the complainant is entitled to get the treatment expenses from the 1^st opposite party. In this case the 2^nd opposite party has no role. Hence this Forum exonerate the 2^nd opposite party from the liability. For the above said reasons, this Forum allow the complaint.

In the result, the 1^st opposite party is directed to pay Rs. 19,381/- to the complainant. Time for compliance one month from the date of receipt of the order. Otherwise 9% annual interest shall paid to the above said amount till the date of realization.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 31^st day of October 2011.

Sd/- BEENAKUMARI. A : MEMBER

Sd/-

G. SIVAPRASAD : PRESIDENT

Sd/-

S.K. SREELA : MEMBER

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C.C. No. 111/2010

APPENDIX

I COMPLAINANT'S WITNESS :

PW1 - K.S. Suresh Chandran Nair

II COMPLAINANT'S DOCUMENTS :

P1 - Copy of notices sent to the 1^st opposite party dated 08.07.2009

and 19.08.2009.

P2 - Copy of registered notice dated 16.09.2009

P3 - Copy of reply notice dated 12.11.2009 from the 1^st opposite

party.

P4 - Copy of treatment bill dated 16.07.2008

P5 - Copy of the treatment bill dated 26.07.2007 to 08.08.2007

III OPPOSITE PARTY'S WITNESS :

NIL

IV OPPOSITE PARTY'S DOCUMENTS :

NIL

Sd/-

PRESIDENT

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