`IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA, Dated this the 15th day of July, 2010. Present : Sri. Jacob Stephen (President). Smt. C. Lathika Bhai (Member) N. Premkumar (Member) C.C.No.123/09 (Filed on 05.09.2009) Between: S.V. Prasannakumar, Syamalavilasom, Vazhamuttom East.P.O., Mallassery, Pathanamthitta. (By Adv. Valsan.T. Koshy) ..... Complainant. And: Manager, New India Assurance Co. Ltd., Branch Office, Changayil Building, College Road, Pathanamthitta. ..... Opposite party. O R D E R Smt. C. Lathika Bhai (Member): The complainant has filed this complaint against the opposite party for getting a relief from this Forum. 2. The fact of the complaint is as follows: The complainant is the holder of mediclaim policy No.760903/34/09/11/00000001 issued by the opposite party. The validity of the policy was from 5.4.2009 to 4.4.2010. On 12,5,09 the complainant was admitted in MGM Muthoot Medical Centre, Pathanamthitta with pain (Lt) lumbar region suggestive of Ureteric colic Headache (+)O/E BP:160/110 mmHG, Urine RE suggestive of UTI. He was inpatient from 12.5.09 to 14.5.09 and incurred a medical expenses of Rs.5,956/- for the treatment. The complainant had lodged a claim before the opposite party for getting the treatment expenses as per the mediclaim policy. But the opposite party rejected his claim based on the policy condition No.4.4.11. The said condition reads as “Diagnostics, X-ray or laboratory examination not consistent with or incidental to the diagnosis of positive existence of any ailment, sickness or injury, for which confinement is required at a hospital/nursing home”. The said condition in the policy is a lion and lamb agreement and therefore it is liable to be subjected to judicial review. The complainant had received a letter from one Medi Assist, which appears to be a Private Ltd. Company with whom the opposite party had entered into some contract. On 14.7.09, the complainant caused to issue a lawyers notice to the opposite party to honour the claim. But the opposite party has not responded. The opposite party is bound to settle the claim of the complainant. The non-settlement of the complainant’s claim is a deficiency in service and amounts to an unfair trade practice. Therefore the complainant filed this complaint for getting the treatment expenses of Rs.5,956/- with interest along with cost from the opposite party. 3. The opposite party has filed a version stating the following contentions: The complaint is not maintainable either in law or on facts. It is admitted that the opposite party had issued a medi claim policy in favour of the complainant for a period from 5.4.09 to 4.4.10 subject to the clause attached to the policy. The opposite party had officially appointed Medi Assist India TPA Pvt. Ltd. All the claims received by the opposite party will be forwarded to Medi Assist India TPA Pvt. Ltd. for processing and for the settlement of the claims. It was seen from the claim form that the complainant was hospitalised at MGM Medical Centre with pain (Lt) left Lumbar region. He was admitted as inpatient from 12.5.09 to 14.5.09. During the period of admission the complainant had undergone investigations to find out the cause of pain at lumbar region. Since no abnormalities were detected he was discharged on 14.5.09. 4. As per Clause 4.4.11 of the Medi claim policy conditions, any medical expenses incurred for or arising out of Diagnostics, X-ray or laboratory examination not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury for which confinement is required at a hospital, Nursing Home, are excluded. As the expenses incurred were not incidental to the diagnosis and treatment of positive existence or incidental of any ailment sickness or injury, the same was repudiated. There is no deficiency in service on the part of opposite party. Under the circumstances, the opposite party prayed for the dismissal of the complaint with their cost. 5. On the above pleadings, the following points were raised for consideration: (1) Whether the complaint is maintainable before this Forum? (2) Whether the reliefs sought for in the complaint are allowable? (3) Reliefs and Costs? 6. The evidence in this case consists of the proof affidavit and Exts.A1 to A6 filed by the complainant. For the opposite party, the Branch Manager, Pathanamthitta of the opposite party filed a proof affidavit and Ext.B1 and B1(a) marked. After closure of the evidence, both sides heard. 7. The complainant’s case is that he had taken a medi claim policy from the opposite party. During the coverage period he was hospitalised with pain (Lt) Lumbar region. He was inpatient from 12.5.09 to 14.5.09. Complainant had lodged a claim before the opposite party for getting the medical expenses incurred by him. But the opposite party had rejected the claim based on the policy condition No.4.4.11 which is illegal and opposed to common sense. 8. For proving his complaint, the complainant has filed a proof affidavit and the documents produced were marked as Ext.A1 to A6. Ext.A1 is the medi claim policy certificate issued by the opposite party. Ext.A2 is the copies of hospital bills. Ext.A3 is the letter sent by the Medi Assist India Pvt. Ltd. to the complainant. Ext.A4 is the copy of lawyers notice issued by the complainant to the opposite party. Ext.A5 is the postal receipt of Ext.A4 and Ext.A6 is the acknowledgment card of Ext.A4. 9. The opposite parties contended that as per Clause 4.4.11 of the medi claim policy conditions, any medical expenses incurred for or arising out of Diagnostics, X-ray or laboratory examination not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital ‘Nursing Home’ are excluded. The expenses incurred to the complainant were not incidental to the diagnosis and treatment of positive existence or incidental of any ailment sickness or injury hence the claim of the complainant was repudiated. 10. In order to prove the contentions of opposite party the Branch Menager, Pathanamthitta has filed a proof affidavit and Ext.B1 and B1(a) were marked. Ext.B1 is the mediclaim policy certificate issued to the complainant. Ext.B1(a) is the policy terms and conditions of the Ext.B1 policy. 11. On going through the evidences in this case it is seen that the complainant had valid policy coverage during his hospitalisation. Ext.A2 shows that he had paid an amount of Rs.5,956/- as hospital bill. Ext.A3 shows that the complainant’s claim was repudiated as per the exclusion Clause 4.4.11 of the policy condition. Clause 4.4.11 of Ext.B1(a) reads as follows:- “Diagnostics, X-ray or laboratory examination not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital/Nursing Home”. The complainant was admitted in the hospital due to the pain of Lumbar region (Lt). Diagnostics, X-ray and in the laboratory examinations, no ailment or abnormality were seen. As the expenses incurred by the complainant was not incidental to the diagnosis and treatment of positive existence incidental of any ailment sickness injury. There is no evidence from the complainant for proving that diagnostics, X-ray or lab tests had diagnosed positive existence of any ailment or he had availed treatment for that illness. 12. Insurance – law is a contract for the benefit of the insured. But the terms and conditions of the contract is binding to both the poarties. The policy condition 4.4.11 in Ext.B1(a) clearly stated that the diagnostics, X-ray or laqboratory examination not consistent with or indicental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury for which confinement is required at a hospital Nursing Home are excluded. On the basis of the policy condition 4.4.11 in Ext.B1(a) the complainant is not entitled to get the hospital expenses incurred by him without finding any ailment and its treatment. In the circumstances, the repudiation of the complainant’s claim by the opposite party can be justified. As per the said exclusion clause, the opposite party repudiated the complainant’s claim hence we cannot find any deficiency in service from the part of opposite party. Therefore, the complainant is not entitled for the benefits under the policy hence the complaint is liable to be dismissed. 13. In the result, the complaint is dismissed. No cost. Declared in the Open Forum on this the 15th day of July, 2010. (Sd/-) C. Lathika Bhai (Member) Sri. Jacob Stephen (President) : (Sd/-) Sri. N. Premkumar (Member) : (Sd/-) Appendix: Witness examined on the side of the complainant: Nil. Exhibits marked on the side of the complainant: A1 : Mediclaim Policy Certificate issued by the opposite party to the complainant. A2 : Photocopy of the hospital bills dated 14.5.09 for Rs.5,956/- issued by MGM Muthoot Medical Centre, Pathanamthitta to the complainant. A2(a) : Photocopy of the Cash Receipt dated 14.5.09 for Rs.5,956/- issued by MGM Muthoot Medical Centre, Pathanamthitta to the complainant. A3 : Letter sent by the Medi Assist India Pvt. Ltd. to the complainant. A4 : Copy of lawyers notice issued by the complainant to the opposite party. A5 : Postal receipt A6 : Acknowledgment card of Ext.A4. Witness examined on the side of the opposite party: Nil. Exhibits marked on the side of the opposite party: B1 : Copy of Mediclaim Policy Certificate B1(a) : Terms and Conditions of the policy. (By Order) Senior Superintendent. Copy to:(1) S.V. Prasannakumar, Syamalavilasom, Vazhamuttom East.P.O., Mallassery, Pathanamthitta. (2) The Manager, New India Assurance Co. Ltd., Branch Office, Changayil Building, College Road, Pathanamthitta. (3) The Stock file.
| | HONORABLE LathikaBhai, Member | HONORABLE Jacob Stephen, PRESIDENT | HONORABLE N.PremKumar, Member | | 
