By Sri. K. Gheevarghese, President:-

The complaint filed under section 12 of the Consumer Protection Act 1986.

The complaint in brief is as follows:- The Complainant is an insured under Janatha Medical Policy of the Opposite Party. The terms and conditions of the policy is such that the Complainant and his wife are insured and the medical expenses of the treatment to the Complainant's wife was assured to be compensated up to an amount of Rs.50,000/-. The Complainant's wife had undergone treatment of breast abscess bilateral in lactating breast and had undergone treatment as an in patient for a period from 19.1.2009 and 12.2.2009. The Complainant spent Rs.20,843/- towards the treatment charge including surgery. The claim of the Complainant for the assured sum of medical expenses was repudiated though submitted with all relevant records on the ground that the treatment cannot be compensated. Since it comes to the exclusion clauses of the policy conditions. There may be an order directing the Opposite Party to give the Complainant Rs.20,843/- with an interest at the rate of 12% from the date of filing this complaint along with cost of Rs.10,000/- and compensation of Rs.1,000/-.

2. The Opposite Party filed version. The sum up of the version filed by the Opposite Party is as follows:- The inception of the Complainant to the policy of medical claim is admitted by the Opposite Party covering the period from 01.02.2008 to 31.01.2009 Rs.1,260/- was also remitted for the same. The terms and conditions of the policy assured that Rs.50,000/- would be paid to the Complainant. The Complainant's wife was treated for breast abscess bilateral lactating breast and had undergone surgery followed by that the patient had undergone treatment as in patient from 19.1.2009 to 12.2.2009 are not within the knowledge of the Opposite Party. The Complainant is bound for the treatment upon conditions as per the Clause No.4.4.13 which explains that the treatment arising from or traceable to pregnancy and all complications with regard to pregnancy etc are excluded from the purview of the policy. The treatment availed by the patient is connected to exclusion clause. The conditions of policy barr the Opposite Party from providing medical expenses. The claim of the Complainant's wife for compensation and cost are exorbitant for which Opposite Party is not liable and these all are not based on reasons. Hence the complaint is to be dismissed with cost.

3. The points in consideration are:-

1. Is there any deficiency in service on the part of the Opposite Party?

2. Relief and cost.

4. Points No.1 and 2:- The evidence in this case consists of proof affidavit of the Complainant and witness of the Opposite Party. Exts. A1, A2, X1 to X7, B1 and B2 are the documents produced in this case. The Medi Assist of the Opposite Party who is examined as OPW1. The doctor who conducted the surgery in the hospital where the patient was treated is examined as PW2.

5. The allegation of the Complainant is that assured sum for the medical expenses to the wife of the Complainant was repudiated by the Opposite Party. According to the Opposite Party the treatment comes within the purview of the exclusion clauses. On verification of the materials on record it is seen that the breast abscess bilateral lactating breast started one week prior to admission. Ext.X2 is the policy conditions 4.4.13 is one among the reason for exclusions which laid down as follows “the treatment arising from for traceable to pregnancy, childbirth, miscarriage, abortion or complications of any of these including cesarean section except abdominal operation for extra uterine pregnancy (Ectopic Pregnancy), which is proved by submission of Ultra Sonographic Report and Certification by Gynaecologist that it is a life threatening one if left untreated”. The repudiation of the claim was in the opinion of Medi Assist who is an expert in the branch of Homeopathy. The treatment availed by the Complainant wife was in the branch of Allopathy. The doctor who conducted the surgery for the patient on examination deposed that the ailment of the patient was due to bacterial inflation and puss formation and this disease is not connected with delivery and pregnancy and the exact cause for the disease of the patient cannot be stated how ever the disease is not due to pregnancy and it happened after the pregnancy. The repudiation of the claim for the insured sum is a deficiency in service. The Complainant produced the medical bills and the receipts for treatment charges on verification of the same. We are in the opinion that the Complainant is to be given the treatment charges of Rs.21,000/- including the other expenses.

In the result, the complaint is partly allowed. The Opposite Party is directed to give the complainant Rs.21,000/- (Rupees Twenty One thousand only) towards the treatment charges. It is also directed to give the Complainant an interest at the rate of 12% from the date of filing this complaint till realization of this amount along with cost of Rs.500/- (Rupees Five hundred only) within one month from the date of receipt of this order.

Pronounced in open Forum on this the day of 28^th July 2010.

PRESIDENT: Sd/-

MEMEBR : Sd/-

MEMBER : Sd/-

A P P E N D I X

Witnesses for the Complainant:

PW1. Byju Scaria. Complainant.

PW2. Dr. A Krishna Kumar Doctor.

Witnesses for the Opposite Party:

OPW1. Dr. Ashok Kumar. Doctor.

Exhibits for the Complainant:

A1. Policy Schedule.

A2. Copy of the Medical Certificate (Attending Doctors Report) dt:14.02.2009.

Exhibits for the Opposite Party:

B1. Request for Cashless Hospitalisation/ Claim form

for Medical Insurance Policy. dt:20.01.2009.

B2. Copy of Letter issued by Vinayaka Hospital. dt:20.01.2009.

X1. Claim Form.

X2. Medical Certificate (Attending Doctors Report) dt:14.02.2009.

X3. Discharge Card.

X4 series. Bills.

X5. Scan Report. dt:21.01.2009.

X6. Hospitalisation Benefit Policy/ Janata Medical Policy.

X7. Janata Mediclaim Policy.