ORDER
PER NIPUR CHANDNA, MEMBER

The complainant was the holder of the individual mediclaim policy no.
350304/48/11/8500000103 valid from 07/04/2011 to 6/4/2012.  It is
alleged by the complainant that on 3-02-2012, the complainant had some
problem in his abdomen and accordingly, He had undergone the diagnosis
and it was found that, he is suffering from actute pancreatitis,
heaviness in abdomen. On the advise of the doctor’s he got himself
admitted in the hospital from 3-02-2012 to 10-02-2012.  It is further
alleged by the complainant as the ailment of the complainant that he
had spent a sum of Rs. 1,17,995/- over his treatment and he informed
the OP about the same.  It is further alleged by the complainant that
he lodged a claim for reimbursement of the said medical bills with the
OP vide claim bearing no. ID no. 60006 for Rs 1,17,995/-. It is
further alleged by the complainant that although the OP was under an
obligation to pay the claim amount to the complainant duly falls under
the scheme of the policy, nothing was done on their part to settle/
pay his genuine claim. Hence, this complaint.
The OP has contested the complaint and has filed the written
statement.  It would be of benefit to reproduce para 3 of the
preliminary objection. It reads as under:-
3. That the said complaint is heavily barred under clause No. 2 of
Additional Conditions in Medi claim Insurance Policy (Individual). As
per Clause No. 2 of the Medi claim Insurance Policy (Individual),
states that “The Company shall not be liable to make any payment under
this policy which states that the company shall not be liable to make
any payment under this policy in respect of any claim if such claim be
in any manner fraudulent or supported by any fraudulent means or
devise whether by the insured person or by any other person acting on
his behalf.” In the present case also the complainant was hospitalized
for the treatment of Acute Chronic Pancreatitis and after the
discharge, when he submitted the claim documents and on scrutiny of
those documents following observations were made :
1) Discrepancy in Room no on IPD and bills (as per Discharge summary
its 109, hut n PL) mentioned as 209) overwriting on IPD. The same
alterations were also found in bills.

2) Diagnosis is Pancreattis but no treatment given for the same.

3) All investigation reports related to pancreatitis i.e. amylase and
lipase are normal were conducted on 08/02/12 just two days before
discharge,

4, Discrepancy in series Cash Receipt no. 20840 is of date 03/02/2012
whereas 20673 (preceding number, is of date 07/02/2Ol2and 20774 is of
10/2/2012 (dates do not match with the reciept number)
5) Discrepancy in series of final bill on 01/02/2012 on bill no. 6186
then on 1012/2012 bill no. 6189, only gap of two bills in ten days
6) X-Ray Film have no number, Date, name and age of patient.
7) There       are   two hospitalization under  tis claim, but age is
different in both IPD record (32& 37)

Both the parties have filed their evidence by way of affidavits.
We have heard the arguments advanced at the bar and have perused the record.
The counsel for the OP has contended that  as per our investigation
the documents were not found to be in order. The diagnosis and the
line of treatment were also not inter-related.  Even, the physical
verification of Hospital was not found to be in order, and , thus the
aforesaid claim falls under the purview of the clause no. 2 of the
additional condition mentioned in the individual mediclaim policy.
The counsel for the OP has further contended that the OP was eminently
justified in repudiating the claim of the complainant,  as there is a
brach of condition of mediclaim policy and prayed for the dismissal of
the complaint.
We, however, are not in agreement with the contention of the counsel
for the OP whatever discrepancy as been pointed out by the respondent
are irrelevant to the matter in issue.  These discrepancies are not on
the part of the complainant.  It is upto the hospital to say about
cash receipts nos, room nos, IPD and the final bill.  Patients
suffering from ailement are concerned only with their health and about
the treatment being given to them whatever the receipts, bills the
hospital are handed over to them, it is not the time to scan them.  It
was of the insurance company / TPA to have verified the admission of
the insured and his treatment at the hospital. We , therefore, is of
the opinion that the OP had repudiated the claim of the complainant on
wrong and flimsy ground.  The aforesaid act of the OP amounts to
deficiency in services.  We, therefore, hold OP guilty of deficiency
in services and direct it as under:
1. Pay to the complainant a sum of Rs. 1,17,995/- along with interest
@ 10% p.a. from the date of filing  of complaint i.e. 24/8/2012 till
payment.
2. Pay to the complainant a sum of Rs. 15,000/- as compensation for
the pain and agony suffered by him.
3. Pay to the complainant a sum of Rs. 5,000/- as cost of litigation.
The OPs shall pay this amount within a period of 30 days from the date
of this order failing which they shall be liable to pay interest on
the entire awarded amount @ 10% per annum.  IF the OPs fail to comply
with this order, the complainant may approach this Forum for execution
of the order under Section 25/27 of the Consumer Protection Act.
Copy of the order be made available to the parties as per rule.  File
be consigned to record room.
Announced in open sitting of the Forum on.....................