This is a complaint filed under section 12 of consumer protection Act for an order directing the opposite parties to pay `4,311 as treatment expenses together with `2000 as  compensation.

          The cases of the complainant is that he had suffered chest pain on 22.11.2010 consequent to which he was admitted Indira Ganhdhi Hospital, Thalassery and shifted to ICU for treatment from 22.11.2010 to 24.11.2010 and incurred expenses `4311.Since he is a policy holder under 1`st opposite party a claim was preferred for the treatment expenses  `4311 with relevant documents. But his claim was rejected on the ground that the hospitalization was only for evaluation purpose. Complainant is the holder of medi claim policy for the last 5 years. So far no claim had been submitted by the complainant. He had been continued to hold the policy by paying `7000 per year. is  H His disease was diagnosed as “Hypertensive Dyslipidemia, Non cardiac chest pain” which is not excluded under the policy of complainant under opposite party. Opposite party rejected the genuine claim of complainant. Complainant had not any claim under any of the previous policies. The request of the complainant before the grievances cell also has not been responded. Hence this complaint.

Pursuant to the notice 1^st opposite party made appearance and filed versin.2^nd opposite party remained silent without filing version. 1^st opposite party contended  as follows: complainant is a policy holder and he had forwarded claim for the reimbursement of the medical expenses of `4,311 towards the treatment for Hypertension, Dyslipidemia and non cardiac chest pain undergone by him during the policy period. But on processing 2^nd opposite party found that the claim of the complainant is not allowable as per the terms and conditions of the policy and thereby the complaint was repudiated. The discharge summary dated 24.11.2010 reveals that complainant was hospitalized only for the purpose of conducting investigation and evaluation of the existence of any disease. His hospitalization from 22.11.2010 to 24.11.2010 was not for any treatment for any disease from the hospital. He was given only oral medicines and daycare procedures  which could have been normally done as an outpatient. The complainant got himself admitted at the Indira Gandhi Hospital, Thalassery for 2 days for conducting investigations for clearing the doubts he had regarding the existence   of any disease to him As per the exclusion clause 4-10 of the Insurance policy the insurer is not liable for the reimbursement of the expenses incurred for evaluation/diagnostic purpose not followed by active treatment during hospitalization. 2^nd opposite party is the 3^rd party administrator of 1^st opposite party, who is empowered to process the claim, to allow or to repudiate the same. The claim of the complainant repudiated on valid ground. Hence to dismiss the complaint.

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

1.     Whether there is any deficiency in service on the part of

               opposite   party?

2.     Whether the complainant is entitled to get the relief as

       prayed in   the complaint?

3. Relief and cost.

The evidence consists of the oral testimony of PW1,DW1, Exts.A1 toA13 and B1 & B2.

Issue Nos.1 to 3

          Admittedly complainant had been a medi-claim insurance policy holder under 1^st opposite party and he preferred a claim for the reimbursement of the medical expense of `4,311.Complaiannt’s case  is that he was taken to hospital due to severe chest pain and admitted at ICU as per the  advice of the doctor from  22.11.2010 to 24.11.2010 and incurred  an expense of `4,311. Claim was preferred but the same was repudiated by opposite party on the ground that the hospitalization is only for evaluation purpose. Request by the complaint to reconsider the repudiation of the claim also has not been taken into account.

          Complainant adduced evidence by means of affidavit that he was admitted to Indira Gandhi Hospital, Thlasery due to severe chest pain. He has further stated that after the preliminary examination he was taken to ICU and undergone treatment from 22.11.2010 to 24.11.2010. These facts were not disputed. The claim of the complainant was repudiated on the ground that the admission was only for evaluation purpose. The medical certificate filed by Dr.T.S. Rajasekher, M.D. Part of Ext.A2 goes to show that the disease of the complainant was diagnosed as “Hypertension and Dyslipidemia Non cardiac chest pain”. Opposite party did not adduce evidence that the above said disease is included in exclusive clause of terms and conditions. Clause 4-10 of terms of policy states that “expenses incurred primarily for evaluation/diagnostic purposes not followed by active treatment during hospitalization”.  It is seen that complainant/patient had been in ICU from 22.11.2010 to 24.11.2010 when a patient is admitted in ICU there is no need of explanation to say that this is a patient who required emergent serious attention. For merely conducting investigations there is no need to   shift the patient in ICU. The very purpose of shifting a patient in ICU is for getting active attention and treatment observing the development every now and then which reveals the seriousness of the situation. Opposite party has no case that he had not been shifted to ICU. Opposite party has not explained how did they derived the conclusion that complainant was admitted for clearing his doubts he had regarding the existence of any disease to him. A patient if shifted to ICU it is u p on the decision of the treating doctor and not the patient. If opposite party has any case that the hospital and doctor unnecessarily shifted the patient in ICU as part of unfair trade practice on the part of hospital it has to be specifically pleaded. Shifting of a patient to ICU in anyway is not depending on the decision of the patient but it is the decision of the docor.Dw1 in cross examination clearly deposed that “ Cu case tUmIvSdpsS \nÀt±i{]ImcamWv 2ZnhkTNnInÕn¨Xp F¶p ]dªm icnbmWv.”. There is no substance in contending that the complainant was sought admission for more investigation.          

          If it is examined further it can be seen that the complainant is policy holder under opposite party for the last many years paying `7000 per year. There is no history of any sort of attempt on the part of complainant at any time erlier to lodge any claim so as to extract money in the account of insurance policy. Complainant specifically pleaded that he has taken the 5<sup>th</sup> policy upon the offer that he is entitled for free check up since he had taken 4 policies continuously. But this complainant had not even availed the free service. It is difficult to  believe that such a person who had not even availed  the free check up attempted to get admission in ICU for earning an amount  `4,311. DW1 in his cross examination deposed that “4 hÀjT XpSÀ¨bmbn medi-claim policyFSp¯m 5þmas¯hÀjT free check up D­v. A{]ImcT free check upsImSp¡m¯Xp lcPn¡mc³ Bhiys¸Sm¯Xn\memWv. .1% of sum assuredBWv free check up \mbn sImSp¡p¶Xp”. It is an admitted fact that he has not availed the free service. No doubt if he is particular he could have avail this opportunity. Opposite party did not produce the report of Dr.Shenoy before the Forum. Moreover, DW1 deposed that it is recorded that the complainant was given oral medicines. He has also deposed that “ AkpJapffXn\memWv tUmIvSÀ medicines prescribesNbvXXp. Medicines are prescribed since he had disease. So this is not a matter of mere investigation.

          Moreover opposite party did not sent reply to lawyer notice.DW1 in cross examination deposed that “ h¡o t\m«oÊn\p R§Ä t\m«oÊb¨n«nà ”. This itself amounts to deficiency in service on the part of opposite party.

          The available evidence on record, facts and circumstances of the case quite clearly reveals that complainant is entitled for the claim amount and repudiation of claim is a deficiency in service. Hence we are of opinion that complainant is entitled for the claim amount `4,311 together with `1000 as compensation and a sum of `1000 as cost of this litigation. The issues 1 to 3 are found in favour of complainant and order passed accordingly.

          In the result, the complaint is allowed directing the 1^st opposite party to pay the claim amount  `4,311  (Rupees Four thousand  Three hundred  and eleven  only)  together with   `1,000 (Rupees One thousand only)compensation and  `1000 (Rupees One Thousand only) as cost of this proceedings to the complainant within one month from the date of receipt of this order, failing which opposite party is liable  to pay 12% interest also upon the entire amount from the date of order till realization of the amount. Complainant is at liberty to execute the order after the expiry of one month as per the provisions of consumer protection Act.  

                      Sd/-                   Sd/-                       Sd/-

President              Member                Member

                           APPENDIX

Exhibits for the complainant

A1.Policy schedule issued by OP

A2. Copy of the claim form

A3.Medical bills

A4 & A5. Copy of the prescription issued from  Indira Gandhi Co.op.

            Hospital, Thalassery.

A6.Copy of the letter dt.21.12.10 sent by 2^nd OP to 1^st OP

A7. Copy of the letter dt.31.1.11 issued by  1st OP

A8. Copy of the letter sent to OP

A9. Copy of the letter sent by 1^st OP

A10.Copy of the letter sent by 2^nd OP to 1^st OP

A11.Letter dt.31.3.11 issued by OP

A12. Copy of the complaint dt.20.5.11 sent to grievance cell of OP

A.A13.Postal AD

Exhibits for the opposite parties:

B1. Medi claim insurance policy

B2. Investigation report.

Witness examined for the complainant

PW1.Complainant

Witness examined for the opposite parties:

 T.V.Sreekumar

                    /forwarded by order/

          Senior Superintendent

Consumer Dispute  Redressal Forum, Kannur.