By Sri.K. Gheevarghese, President:<br /> <br /> The complaint filed under section 12 of the Consumer Protection Act.<br /> The complaint in brief is as follows:<br /> The Complainant is a holder of the Family Health Planning Scheme of Rs.50,000/- . The policy Number of the scheme is 050400/48/04/00350 at the plan period covers in between 22.6.2004 and 8.6.2005. The Complainant become the holder of the policy remitting<br /> Rs. 300/- in the 2nd Opposite party Bank dated, 22.8.2006. The terms of the policy is such<br /> (Contd.........2)<br /> -2-<br /> that if the Complainant meet with accident or in diseases. The expenses of the treatment is to be paid by the insurer. The policy premium of Rs. 900/- was remitted at the time of joining. The Complainant has admitted Vinayaka Hospital, S. Bathery for the treatment of Dogbite as out patient on later she was again admitted as in patient on 23.8.2004 and discharged on 24.8.2004. The expense towards the treatment was Rs. 1415/- . The Ist Opposite party was informed of this treatment along with the service and the bills was sent on 10.9.2004 but the medi claim of the Complainant was refused on 30.9.2004. The reason for the rejection of the claim was that the Complainant is not required to under go the treatment as in patient in the hospital for Dogbite. The repudiation of the claim is a deficiency in service of the Complainant. The Opposite party is to be directed to give the Complainant Rs. 1415/-. The treatment charges along with Rs. 5,000/- towards mental agony and Rs. 2000/- towards the cost of the petition.<br /> <br /> The Opposite parties No.2 and 3 filed version on their appearance. The opposite party No.1 did not file the version. The 2nd Opposite party admitted, the admission of the Complainant in Family Health Planning under United India Insurance Company Limited. The<br /> scheme provides Medi Claim Insurance with United India Insurance Company Limited meant for Andra Bank Customers on special rates. The policy holder can opt for the service in one of the five third party administrators authorised by Government of India Insurance Company. The party who issued the policy is not impleaded. The petition is bad for non joints of necessary parties. The premium collected by the 2nd Opposite party is given to United India Insurance Company Limited and the Medi claim if payable to the Complainant is to be done<br /> by them. On issuance of the policy to the policy holder if effected, the role of the 2nd Opposite party ceased to exist. The further transactions or any claim evented, the policy<br /> (Contd........4)<br /> -4-<br /> holder has to contact the United India Insurance Company or the approved third party administrator as the case. The 2nd Opposite party has not informed of any hospitalization or treatment. There is no deficiency in service on the part of the 2nd Opposite party. The Complaint is to be dismissed with compensatory cost. The 3rd Opposite party is impleaded and version filed on their appearance. The 3rd Opposite party also admitted the insurers Complainant. The scheme titled as Arogyadhan Medi Claim Policy No. 050400/48//04/00350 through the 2nd Opposite party Andra Bank. The Complainant submit the claim form to the Ist Opposite party who is the 3rd Opposite party administrator. Stating that she had undergone inpatient treatment in Vinayaka Hospital but from 23.8.2004 to 24.8.2004 . The amount claim for the Medical reimbursement in Rs. 1415.49/-. The medical team under the Ist Opposite party verify the claim and found that the claim doesn't come under. The per view of the policy for the reasons (1) The insured is a holder of the fresh policy and the date of the policy inception is 22 June 2004. The insured was admitted in the hospital on 23.8.2004 for the treatment of dogbite on 17.8.2004. The discharge summary shows that the patient had three injection on 14.8.2004, 20.4.2004 and 24.8.2004. No other detail of the treatment was<br /> given in discharge summary except the bills. The documents submitted in relation with the treatment do not necessitate the treatment as in patient. The Complainant could have availed out patient treatment. The claim was repudiated in this ground on 30.9.2004. The complaint filed is on untenable grounds and is to be dismissed with cost to the Opposite party.<br /> <br /> The points in consideration are:<br /> 1. Is there any deficiency in service on the part of the Opposite party?<br /> 2. Relief and cost? <br /> (Contd........5)<br /> <br /> -5-<br /> Point No.1<br /> The Complainant is examined as PW1. Ext. A1 is the Medi claim insurance form. The letter send to the Family Health Planning Pvt. Ltd is the Ext. A2. The Complainant is discharged from Vinayaka Hospital, the photocopy of the discharge card is Ext. A3 . The date of admission was on 23.8.2004 and discharged on 24.8.2004. Ext. A4 is the photocopy of cash bills. The amount paid in the hospital is detailed in Ext. A4 to A9. The doctor who treated the Complainant is examined as PW2. It is deposed that according to the Ext. A9 the patient availed the treatment as in patient. The treatment of the Complainant as in patient was due to strong musil pain. The treatment given requires close observation and for which the Complainant was admitted. The Complainant had under gone in patients treatment. Ext. B1 is the attested photocopy of the Arogyadhan group medical claim insurance proposal forum with Andra Bank account holders. As per the features of the group medi claim insurance policy close to offers that the medical expenses for the insured more than 24 hours covers the risk under the claim. The doctor who treated the Complainant deposed that the nature of the treatment requires close observation for which the Complainant is treated in patient. The<br /> repudiation of the claim by the Opposite party is no supported by sufficient reason. The point No.1 is found in favour of the Complainant.<br /> <br /> Point No.2<br /> The Arogyadan Group Medi claim insurance is the claim of insurance designed for the account holders of Andra bank as per the Ext. B1 and admitted by the Opposite parties. The liability of the insured is to be met with the United India Insurance Company envisaged in the policy. The Complainant remitted the policy premium and became the holder of the scheme. Ext. A4 to A9 are the receipts produced by the Complainant of the amount paid in the hospital.<br /> (Contd.........6)<br /> -6-<br /> The treatment charges of the Complainant as to be met by the Opposite party. Where as the Ist and 2nd Opposite parties are only the promoters who made the Complainant to join in the claim of insurance. Hence the liability to meet the claim amount vests upon the 3rd Opposite party. The Complainant is also to be paid Rs. 2000/- towards the cost and compensation. <br /> <br /> In the result the 3rd Opposite party is directed to give the Complainant Rs. 1,415/-( Rupees one thousand four hundred and fifteen only) along with Rs.2,000/-(Rupees two thousand only) towards the cost and compensation in case of any failure on the part of the 3rd Opposite parties, the Complainant is entertain to execute this order as per the provisions of law.<br /> Pronounced in open forum on this the 22nd day of February 2008.<br /> <br /> PRESIDENT: Sd/-<br /> MEMBER : Sd/-<br /> /True copy/ <br /> PRESIDENT, CDRF WAYANAD.<br /> APPENDIX<br /> <br /> Witnesses for the Complainant<br /> PW1 Marudevi Avva Complainant<br /> PW2 Dr. Omana Madhusoodanan Doctor<br /> Witnesses for the Opposite party<br /> Nil<br /> <br /> (Contd.......7)<br /> -7-<br /> Exhibits for the Complainant<br /> A1 Mediclaim insurance policy<br /> A2 Letter<br /> A3 Discharge Card<br /> A4 Cash Bill<br /> A5 Cash Bill<br /> A6 Cash Bill<br /> A7 Cash Bill<br /> A8 Cash Bill<br /> A9 Discharge Bill<br /> <br /> Exhibits for the Opposite party:<br /> <br /> B1 Medi claim Insurance Proposal form<br /> <br /> <br /> <br /> PRESIDENT, CDRF WAYANAD.