By Sri. P. Raveendran Member:

Brief of the complaint:- The Opposite Parties are engaged in the business of Health Insurance. During November 2009 opposite parties agent called the Complainant and her husband to join their health insurance scheme. So the Complainant and her husband joined in the insurance scheme. The Opposite Parties issued health insurance policy bearing policy No.P/181314/01/2010/002827 from 31.10.2009 to 30.10.2010 by collecting a premium of Rs.3,309/-. On 30.09.2010 the Complainant was admitted in MIMS Hospital Calicut with chest pain. A team of Doctors examined her and advised to take coronary angiogram and the same was done 01.10.2010. She was discharged on 02.10.2010. A claim form was sent for reimburse for Rs.13,123/-. But in December 2010 the Opposite Party repudiated the claim. Hence it is prayed to pass an order directing the Opposite Parties to pay Rs.13,125/- with 18% interest from 02.10.2010, Rs.25,000/- as compensation and cost of this litigation.

2. Opposite Parties appeared and filed their version. In the version they admitted that medi claim policy was issued to the Complainant and her husband by 1^st Opposite Party from 31.10.2009 to 30.10.2010. The exclusion clause in paragraph No.13 of the contract of policy specifically excluded the expenses for evaluation and investigation of any disease. As a matter of fact, the Complainant was admitted on 30.09.2010 at MIMS hospital Calicut with a typical chest pain and underwent coronary angiogram. The insured has submitted completed claim form with Medical Certificate and bills for Rs.13,650/- and lab report on 22.10.2010 which will not fall under the scope of our policy at all. The investigation confirmed that the patient is not suffering from any illness. The above claim of the insured falls under exclusion clause No.13 of the policy contract the Opposite Parties are not liable to pay the claim amount to the Complainant. Hence the Forum may be dismissed the complaint with cost.

3. On considering the complaint and version the following points are to be considered.

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

2. Relief and cost.

4. Point No.1:- To prove Complainant's case she has filed her proof affidavit and Exts.A1 to A3 are also marked. To prove Opposite Parties case the chief affidavit of One P.S Dileepkumar is filed on behalf of the Opposite Parties. They have also produced Exts.B1 to B8 documents. In this case the insurance is admitted by Opposite Parties. But according to them the admission and tests were done only to ascertain any disease. So it come under the exclusion clause hence they repudiated the claim. We have perused the Ext.A2 series document and Ext.B3 document ie the discharge summary of the Complainant issued from MIMS Hospital Calicut. On perusing the above documents it revealed that the Complainant is admitted their complaining chest pain. To ascertain the exact cause of chest pain the doctors who treated her conducted the tests including coronary angiogram. The doctors who have treated her prescribed medicines to her. At the time of discharge also they have prescribed medicines to her. She was advised to review after 3 months in cardiology. It means that she was admitted in MIMS Hospital with chest pain. So it will not come under the exclusion clause of the policy issued by Opposite Party. No contra medical evidence is adduced by Opposite Parties. Hence the repudiation on the part of the Opposite Parties are deficiency of service on the part of the Opposite Parties. Point No.1 is decided accordingly.

5. Point No.2:- On perusing Ext.A1 it is clear that the Complainant is insured for a sum of Rs.1,00,000/-. Ext.A2 shows that the Complainant has spent Rs..13,126/- for her treatment. Hence she is entitled to get that amount along with 10% interest from 24.02.2011 till the payment of that amount by Opposite Parties. She is also entitled to get Rs.500/- as cost of this litigation from the Opposite Parties.

6. In the result, the complaint is partly allowed and Opposite Parties are directed to pay Rs.13,126/- to the Complainant with 10% interest from 24.02.2011 till the payment is made. Opposite Parties are also directed to pay Rs.500/- (Rupees five hundred only) as cost of this litigation to the Complainant.

The order is to be complied with 30 days of this order

Pronounced in open Forum on this the day of 29^th July 2011.

Date of filing:24.02.2011.

PRESIDENT: Sd/-

MEMBER : Sd/-

MEMBER : Sd/-

/True copy/

Sd/-

PRESIDENT, CDRF, WAYANAD.

A P P E N D I X

Witness for the Complainant:

PW1. Amina Complainant.

Witness for the Opposite Parties:

OPW1. P.S. Dileepkumar. Asst. Manager, Star Health & Allied Insurance Company.

Exhibits for the Complainant:

A1. Medi Classic Individual Policy Schedule.

A2 series Discharge Summary.

A3. Copy of Claim Repudiation Letter. dt:21.12.2010.

Exhibits for the Opposite Parties:

B1. Copy of Proposal Form.

B2. Copy of Claim form for medical Insurance.

B3. Copy of Laboratory Results.

B4. Copy of Coronary Angiogram Report.

B5. Copy of Photograph.

B6. Copy of E.C.G Report.

B7. Medi Classic Individual Policy Schedule.

B8(Marked with objection). Letter of Authorisation. dt:23.07.2011.