STATE CONSUMER DISPUTES REDRESSAL COMMISSION KERALA FIRST APPEAL NO. SC/32/A/174/2020 DR.GEORGE IMMANUEL PRESENT ADDRESS - Maridom kara, Kadaplamootam P.O, Meenachil taluk, Kottayam District ,KERALA.

.......Appellant(s)

Versus NATIONAL INSURANCE CO LTD PRESENT ADDRESS - Palai branch, Represented by its Branch Manager, George Arcade, Erattupetta road, Pala- 686 575 ,KERALA.

.......Respondent(s)

BEFORE:

SRI.RADHAKRISHNAN.K.R , PRESIDING MEMBER FOR THE APPELLANT:

NEMO FOR THE RESPONDENT:

NEMO DATED: 23/05/2025

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM APPEAL No.174/2020 ORDER DATED : 23.05.2025 (Against the order in C.C.No.248/2017 on the files of DCDRC, Kottayam)

PRESENT:

HON’BLE JUSTICE SRI. B. SUDHEENDRA KUMAR : PRESIDENT SRI. AJITH KUMAR D. : JUDICIAL MEMBER SRI. K.R. RADHAKRISHNAN : MEMBER APPELLANT:

Dr. George Emmanuel, S/o Emmanuel, Olickal House, Maridom Kara, Kadaplamattom P.O., Meenachil Taluk, Kottayam District. Pin-686571.

(by Adv. Sreevaraham N. G. Mahesh)

Vs.

RESPONDENT:

The National Insurance Co. Ltd., Palai Branch. Represented by its Branch

Manager, St. George arcade, Erattupetta Road, Pala – 686575

JUDGEMENT

SRI. K.R. RADHAKRISHNAN: MEMBER This is an appeal filed u/s 41 of the Consumer Protection Act, 2019 by the complainant in C. C. No. 248/2017on the files of the District Consumer Disputes Redressal Commission, Kottayam (the “District Commission” for short). As per the order dated 29/06/2020 the District Commission dismissed the complaint. The complainant challenges the said order:

2. Brief details of the complaint are as follows:

The complainant had taken a Health Insurance Policy No. 570601/48/16/8500000365 from the opposite party for covering himself, wife and children for a sum insured of Rs.2,00,000/-(Rupees Two Lakh Only) for the period from 09/08/2016 to 08/08/2017. He had been taking the policy from the opposite party from 09/08/2005 onwards without any break. The complainant had undergone a treatment for Fistula in anus at Al-Shifa Super Speciality Hospital, Ernakulum. He was admitted on 23/06/2017 and the surgery was done on the same day. He was discharged on 28/06/2017. The complainant had submitted duly filled claim form and other required documents to the opposite party insurer on 18/07/2017 for getting reimbursement of treatment expenses of Rs.1,25,685(Rupees One Lakh Twenty Five Thousand Six Hundred and Eighty Five only). The Third Party Administrator (TPA), Dedicated Services Private Limited, settled the claim for Rs.47, 959/- (Rupees Forty Seven Thousand Nine Hundred and Fifty Nine Only) only. Balance amount of Rs.67,750/-(Rupees Sixty Seven Thousand Seven Hundred and Fifty only) was not paid on the ground that treatment for haemorrhoidectomy is payable only up to the extent of expenses incurred for the reasonable and standard treatment, charged by other hospitals in the locality. It was also stated that expenses incurred for the advanced laser technology is not admissible. According to the complainant the unilateral deduction made by the opposite party is unreasonable and inconsistent with the terms and conditions of the contract of insurance. Hence, the complaint was filed claiming the balance amount Rs.67,750/-(Rupees Sixty Seven Thousand Seven Hundred and Fifty Only) with interest and Rs.50,000/-(Rupees Fifty Thousand Only) as compensation and costs.

3. Notice was issued to the opposite party who appeared and filed the version. The opposite party submitted that the treatment expenses and post hospitalisation expenses claimed by the complainant are highly exorbitant and about 3 times higher than the normal rate of expenses in similar hospitals in the same locality for the same treatment. The opposite party is liable to pay only reasonable and standard expenses, which was already paid by the TPA. The balance amount of the claim was not paid as per clause 3.18 of the definition clause and operative clause no.2 of the policy. The opposite party insurer is not liabl