This is a complaint filed under sectin12 of consumer protection Act for an amount of  `6344 as claim amount together with cost.

          The case of the complainant in brief is as follows:  Complainant consulted with Superior Neurologist Dr.N.Shankar at Mangalore due to unbearable neck pain. He advised upper spine X-ray. As a result he was hospitalized on 25^th June 2009 and also MRI was taken. Since there was serious defect in MRI he was advised for surgery. As he was not prepared for operation he was discharged from the hospital. After the admission the complainant and the hospital authorities tried to contact M/s.Medi Asst. (P) Ltd, Bangalore for cashless hospitalization but there was no response. After his discharge he submitted hospital bill to M/s.Medi Asst.(I) Ltd. But it was denied. Complainant again explained along with medical certificate but that too denied. No reply sent to complainant but the denying letter sent to Syndicate Bank Head office, Manipal and the same redirected to him. As per law 24 hours hospitalization is enough for allowing the bill. It is doctor who decides where the patient should have been hospitalized. Opposite party’s case is that the Mangala Hospital where he was admitted does not confirm the requirement of the policy condition. It is wrong since the bill of his wife who was also admitted in the same hospital allowed by her insurance company. He could understand that this TPA has already passed their so many bills. It only shows there is something wrong with the TPA. This case was brought to the notice of the United India Assurance Co. Ltd, Divisional Office, Udupi, Reply was received from them stating that they confirm the denying letter of 1^st opposite party. Hence this complaint.

          In pursuance of the notice opposite parties appeared and filed version by 1^st opposite party separately. The case of the 1^st opposite party in brief is as follows: 1^st opposite party is the 3^rd part Administrators of United India Insurance co. Ltd. Appointed for claim settlement. The complainant was admitted to Mangala Hospital Mangalore for complaints Lumbar. Spondylosis, Allergic Pharyngitis- Hypertension etc from 25.6.09 to 27.6.09. After discharge claim submitted for reimbursement of `6344 along with the requisite documents for processing of the same. On the scrutiny of the documents the complainant was admitted to hospital for lumbar spondylosis with hypertension which ailment he was having since last 15 years. So the ailments are preexisting one prior to the inception of the policy cover. As per records it could be revealed that complainant was mainly admitted for MRI scan. The complainant during the period of hospitalization investigations only done without any line of treatment. All investigation is day care procedures and can be done on OPD basis and only oral medications are advised during admission period as symptomatic treatment. The claim repudiated on the basis of terms, conditions and Exclusions. There is no deficiency in service on the part of opposite party.

          Opposite parties 2 and 3 jointly filed the version the brief of which is as follows: Syndicate Bank Manipal is the insured and thus necessary party. Complaint is bad for non-joinder of necessary party. The liability of company is governed as per terms, conditions, exclusions and exceptions in the policy.  Complainant was admitted to Mangala Hospital, Mangalore for complaint of Lumbar Spondylossis, Allergic pharyngitis Hypertension from 25.6.09 to 27.6.09. Complainant submitted a claim for `6344. As per discharge summary the complainant was having the ailment since 15 years. So these ailments are pre-existing one prior to the inception of the policy cover. As per medical records the complainant was mainly admitted for MRI Scan. Complainant during hospitalization only investigations done without any line of treatment. All investigations are day care procedures and can be done on OPD basis and only oral medications are advised treatment was at a hospital which does not confirm to requirements of policy conditions. Complainant is not entitled for any relief. There is no deficiency on the part of the opposite party. Hence to dismiss the complaint.

On the above pleadings the following issues  have been taken for consideration.

1. Whether there is any deficiency on the part of opposite

     party?

2. Whether the complainant is entitled for the relief as prayed in

     the complaint?

3. Relief and cost.

The evidence consists of oral testimony of PW1, Exts.A1 to A9

Issue Nos.1 to 3

          Admittedly complainant was hospitalized from 25.6.09 to 27.6.09. After discharge he submitted claim for reimbursement of `6344 along with the requisite documents for processing the same. But the claim was repudiated on the ground that the ailments are preexisting one prior to the inception of the policy cover.

          Complainant adduced evidence by way of chief affidavit in tune with the pleadings. He has stated that he was hospitalized in Mangala hospital, Mangalore and advised for MRI scan and prescribed medicines. He was also advised for neck surgery. Since he was not prepared for surgery he was discharged from hospital on 27.6.09. He was prescribed 2 weeks medicines for improving the balancing system of his body. By mistake the doctor forgotten to mention the seriousness of the MRI scan and advise of surgery in the discharge summary. He further stated that when he submitted the hospital bill the TPA denied his medical bills stating that he was mainly admitted for MRI scan. Besides, the opposite parties had informed him that these ailments are pre existing one. But as per the letter circulated to all pensioners by syndicate Bank, the insurance policy covers the hospitalization expenses in respect of treatment for all diseases including pre-existing diseases. Complainant also stated that during the period of hospitalisation, medicinal treatment also was given to him along with the investigation.

          Opposite party did not adduce neither oral nor produced documentary evidence. Apart from adducing evidence by way of affidavit in lieu of chief examination complainant produced Exs.A1 to A9 for supporting his pleadings. Opposite parties admitted the policy coverage and hospitalisation. Though opposite party has the case that ailment of the complainant was a pre-existing disease opposite party failed to prove it.

          Ext.A8 proves that complainant was admitted in Mangala Hospital & Mangala Kidney foundation on 25.6.09 and discharged on 27.6.09. It also proves diagnosis as Lumbar Spondylosis, allergic pharyngilis and Hyper tension on diet. Ext.A6 is a very relevant document which has not been challenged by opposite party. The letter written by Syndicate Bank   regarding Medi-claim Insurance scheme for superannuated officers/workmen Employees specifically stated that “the insurance policy covers the hospitalisation expenses in respect of treatment for injury due to accident and all diseases including pre-existing disease except pre-existing cancer”.  Opposite party has no case that complainant has suffered pre-existing cancer. If that be  so what is the ground practically existing to deny the claim of the complainant. Ext.A6 if issued against the terms and conditions of insurance policy holding by complainant it should have been taken as a separate contention. Opposite parties have no case that Ext.A6 is issued opposed to the terms of the policy. So much discussion is not necessary to hold that opposite parties are liable to pay the treatment expenses of the complainant. Exclusion clause 4-10 has not been proved in this case on the one hand and the same in the light of Ext.A6 has no application. If Ext.A6 has been found wrong it should have been challenged by the insurance company. If that is a misleading statement it is the insurance company who has to challenge it without fail.

          In the above circumstances we are of considered opinion that opposite parties are liable to pay the treatment expenses of complainant. Thus it is held that the opposite parties are liable to pay the hospital bill `6350 as is detailed in Ext.A1. Complainant is also entitled for sum of `500/- as cost of this litigation. Hence issues 1 to 3 are partly found in favour of complainant.

          In the result, the complaint is allowed partly directing the   opposite party to pay a sum of `6350 (Rupees Six thousand three hundred and fifty only) as treatment bill and a sum of `500 (Rupees Five hundred only) as cost of this litigation within one month from the date of receipt of this order failing which the complainant is at liberty to execute the order as per the provisions of the consumer protection Act.

                         Sd/-                    Sd/-                     Sd/-

President              Member                Member

APPENDIX

Exhibits for the complainant

 A1.Copy of the letter dt.29.6.09 sent to OP

A2 .Copy of the letter issued by OP

A3. Copy of the Certificate from Dr.Sankar

A4. Copy of the letter dt.14.8.09 sent by OP

A5. Copy of the Prescription of Neuro surgeon Dr.Suresh

A6. Copy of the Letter from Syndicate Bank dt.22.11.08

A7. Copy of the Medi claim policy

A8.  Copy of the Discharge summary from Mangala Hospital

A9.Copy of the letter dt.16.2.11 issued by Syndicate Bank

Exhibits for the opposite party:  Nil

Witness examined for the complainant

PW1.Complainant

 Witness examined for the opposite party: Nil

                  /forwarded by order/

          Senior Superintendent

Consumer Dispute  Redressal Forum, Kannur.