Kerala

Idukki

CC/176/2020

James Sebastian - Complainant(s)

Versus

Oriental insurance co ,ltd - Opp.Party(s)

Adv:K M Sanu

20 Oct 2022

ORDER

 

DATE OF FILING : 15/12/2020

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the 20^th day of October 2022

Present :

              SRI.C.SURESHKUMAR                                               PRESIDENT

              SMT.ASAMOL P.                                                          MEMBER

              SRI.AMPADY K.S.                                                        MEMBER

CC NO.176/2020

Between

Complainant                            :   James Sebastian,

                                                     Uppumakkal House, Vannappuram P.O.,

                                                     Thodupuzha.

                                                     (By Adv.K.M.Sanu)

                                                           And

Opposite Party :                   :   1 .  The Manager,

                                                       Oriental Insurance Co.Ltd.,

                                                       Kadavanthra, Ernakulam.

                                                  2  .  The Manager,

                                                         Oriental Insurance Co.Ltd., Jyothi Super Bazar,

                                                         Thodupuzha, Thodupuzha P.O.

                                                   3 .  The Manager,

                                              GOOD HEALTH  INSU, Ashoka my Home Chambers,

                                              Sardar Patel Road, Secunderabad, Telungana – 500 003.

 

O R D E R

SMT.ASAMOL P., MEMBER

 

Case of complainant is briefly discussed hereunder:-

 

1 . Complainant is an account holder in Punjab National Bank for long  years. When opposite parties and Punjab National Bank started together PNB-Oriental Mediclaim Policy, complainant joined as a member in this policy in 2013.  Complainant has been renewed this policy and during the period from 25/02/2019 to 24/02/2020, he has renewed this policy with paying Rs.14,116/- as premium amount. 

 

                                                                                                                 (Cont.....2)

 

-2-

As per this policy, opposite parties had offered upto 3 Lakhs rupees for treatment of complainant, his wife and son.  Now, this policy is renewed for 5 lakhs coverage with paying premium of Rs.19,753/-.

2 .  On 16/12/2019, wife of complainant was admitted in Jubily Mission Medical College Hospital, Thrissur due to heart problems.  Thereafter, she was admitted 3 days in Rajagiri Hospital, Aluva for other check-up such as ECG etc.,  After these check-up, doctors found that she has ‘Transient Ischnic Attack’ and medicines was prescribed for one month.  For medicines and treatment, complainant has incurred Rs.33,317/-.   

After discharging from the hospital, complainant had applied for claim amount along with required documents.  The application was filed in 2020 January itself.   However, opposite parties didn’t give the claim amount till this date.   This is deficiency in service on the part of opposite parties.  Hence opposite parties are liable to give Rs.33,317/-, as claim amount to complainant.   Hence complainant has prayed the following reliefs.

1.  Opposite parties may be directed to pay Rs.33,317/- as cost of treatment along with 18% interest since December, 2019.
2.  Opposite parties may be directed to pay Rs.20,000/- as compensation for mental agony.
3. Opposite parties may be directed to pay Rs.5000/- as cost of litigation.

        Commission has served notice to opposite parties.  Even though opposite parties were represented by counsel, no vakalath or written version filed.  Hence, opposite parties  were called absent and set exparte.  Thereafter, case was posted for evidence of complainant.

Complainant has not adduced oral evidence.  3 documents were produced.  These were marked as Exts. P1 to P3.  Complaint was heard and it was taken for orders.  Now, the points which arise for consideration are:-

1. Whether there is any deficiency in service on the part of opposite parties?
2. If, so, complainant is entitled for what relief?
3.  

 

 

1.  

The Points are considered

 

          We have gone through the complaint.  After perusing the documents, we are considering the complaint.  Opposite parties have not adduced any evidence.  They have not appeared or represented before the Commission.  Complainant had produced policy copy.  It is seen that complainant was insured including his wife and son with PNB-Oriental Mediclaim Policy during the period from 25/02/2019 to 24/02/2020.  As per this policy, Oriental Insurance Company Ltd., is the insurer and M/s GOOD HEALTH INSUR is the insurance company.  During the policy period, complainant’s wife was hospitalized for 3 days and medical treatment for one month.  As per Ext.P2,  complainant has incurred Rs.32,800/- for treatment.  Complainant has alleged that opposite parties did not give the claim amount as per the policy.  According to complainant, he had requested to third opposite party by a claim process letter along with required documents.  But they did not consider his letter.  This letter was produced and marked.  We are of the considered view that there is deficiency in service on the part of  opposite parties.  Hence complaint is partly allowed as hereunder.

     (a)  Opposite parties are directed to pay Rs.32,800/- as per Ext.P2 to complainant.

     (b) Opposite parties are directed to pay Rs.10,000/- as compensation and to pay Rs.5000/- as cost of litigation to complainant within 45 days from the date of copy of receipt of this order, failing which the amount except cost of litigation shall carry 12% interest from the date of order till its realisation.

Pronounced by this Commission on this the 20^th day of October, 2022.

 

                                                                           Sd/-

                                                                            SMT.ASAMOL P., MEMBER 

                                                                                           Sd/-

                                                                     SRI.C.SURESHKUMAR, PRESIDENT 

                                                                                           Sd/-

                                                                   SRI.AMPADY K.S., MEMBER

 

 

 

                                                                                                                 (Cont.....4)

 

-4-

APPENDIX

 

Depositions :

On the side of the Complainant :

Nil

On the side of the Opposite Party :

Nil

Exhibits :

On the side of the Complainant :

Ext.P1 – Copy of PNB-Oriental Mediclaim Policy - 2017

Ext.P2 – Copy of outpatient receipt dated 16/12/2019 and inpatient bill

Ext.P3 – Copy of letter from complainant to the Manager, M/s Good Health Insur

On the side of the Opposite Party :

Nil                                                                                       

                                                                                               Forwarded by Order

 

                                                                                        ASSISTANT REGISTRAR