By Sri. Chandran Alachery, Member:

The complaint is filed under section 12 of the Consumer Protection Act for an order directing the Opposite parties to pay Rs.60,975/- to the complainant towards treatment expenses, to pay Rs.25,000/- as compensation, to pay Rs.2,000/- as cost of the lawyer notice and to pay the cost of the proceedings.

2. Complaint in brief:- Due to the instigation of 3^rd Opposite Party, the Complainant took a policy from 1^st and 2^nd Opposite parties on 09.09.2013 named Senior Citizen Red Carpet Policy. The sum assured amount is Rs.1,00,000/-. At the time of joining the policy the 3^rd Opposite Party assured that the policy have coverage for all diseases and cashless benefit for admission and treatment for more than 24 months. The Complainant used to renew the policy from time to time. While so, the Complainant admitted at Baby Memorial Hospital on 15.08.2016 for heart disease and undergone Angioplasty and put stent. The Complainant was discharged on 19.08.2016. The Opposite Parties denied cashless benefit to the Complainant. After discharge, the Complainant submitted claim application with all necessary documents and medical bills for the reimbursement of Rs.1,87,000/-. But the Opposite Parties paid only Rs.39,025/- towards medical expenses. The act of Opposite Parties are unfair trade practice and deficiency of service from their side.

3. On receipt of complaint, notices were issued to the opposite parties and opposite party No.1 and 2 appeared before the Forum and filed version. Opposite party No.3 not appeared and not filed version and hence opposite party No.3 is set ex-parte. In the version of opposite party No.1 and 2, they contented that at the time of availing of policy, the complainant was supplied with the terms and conditions and explained it to the complainant. As per terms, exclusion clause 5 reads that 50% of the each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured. The expenses of room rent, boarding, nursing expenses maximum of 1000 per day (ie 1% of SA, ICU Charges,2% of SA ie 2000 per day, surgeon, Anesthetist, Doctor, Consultation fee, 25% of SA ie maximum 25,000/- per hospitalization, Anesthesia, blood, oxygen, operation theatre, surgery etc 50% of SA ie maximum of 50,000/- hospitalization. The admissible amount is Rs.55,750/-. By applying 30% co-pay, Rs.16,725/- has to be deducted from admissible amount and the balance payable amount is Rs.39,025/-. The opposite party already paid Rs.39,025/- to the complainant. Hence there is no deficiency of service from the part of opposite party No.1 and 2.

4. On perusal of complaint, version and documents, the Forum raised the following points for consideration:-

1. Whether there is any deficiency of service from the part of opposite parties?

2. Relief and Cost.

5. Point No.1:- The complainant filed proof affidavit and is examined as PW1 and documents are marked as Ext.A1 to A4. Opposite party No.1 and 2 filed proof affidavit and the opposite party No.1 and 2 is examined as OPW1 and documents are marked as Ext.B1 to B5. Confronted document is marked as Ext.A5. Ext.A1 is the Copy of Lawyer Notice issued by the complainant to the opposite parties. Ext.A2 is the Postal Receipt, Ext.A3 is the Acknowledgement Card, Ext.A4 is the Reply Notice send by the opposite parties to the complainant, Ext.A5 is the copy of Final IP Bill. Ext.B1 is the Copy of Proposal Form, Ext.B2 is the Policy Schedule, Ext.B3 is the Claim Form copy, Ext.B4 is the Copy of Discharge Summary, Ext.B5 is the Bill Assessment Sheet. As per Ext.B2 document, clause 5 of policy condition states that the policy is subject to co-payment of 50% of each and every claim arising out of Pre-existing diseases and 30% of each and every claim for all other claims which are to be borne by the insured. On perusal of Ext.A5 final bill issued to the Complainant by the hospital, on 16.08.2016, coronory Angiography procedure charge of Rs.7,500/- and on 17.08.2016, elective angioplasty procedure charge of Rs.55,000/- was ssen levied from the Complainant. As per Ext.B2(2) policy condition clause D, 50% of the sum assured is the maximum amount payable under this headm, the Complainant claimed Rs.62,960/- but the Opposite party not sanctioned any amount in this head why the Opposite party sanctioned any amount under this head is not proved by the Opposite Party. The Forum found that after deducting 30% co-pay, the Complainant is entitled to get 70% of the proceedure charges ie Rs.35,000/-. All other calculations made by the Opposite party is seen correct. Not allowing any amount under proceedure head is a clear deficiency of servie from the aprt of Opposite party. Point No.1 found accordingly. The cause of complainant is that the complainant joined in to the policy through opposite party No.3 and he was not explained with the policy conditions. The case of complainant is that at the time of signing Proposal Form opposite party No.3 assured the entire hospitalization expenses if a treatment is undergone by the complainant. In this case, opposite party No.3 is ex-parte. Opposite party No.3 is only an agent of 1^st and 2^nd Opposite Parties. Any how parties are bound by the terms and conditions of the policy.

6. Point No.2:- Since the Point No.1 is found in favour of the complainant, the complainant is entitled to get cost and compensation.

In the result, the complaint is partly allowed and the opposite party No.1 and 2 are directed to pay Rs.35,000/- (Rupees Thirty Five Thousand) towards Hospital Expenses and also directed to pay Rs.3,000/- (Rupees Three thousand) as compensation and Rs.2,000/- (Rupees Two thousand) as cost of the proceedings. The Opposite Parties No.1 and 2 are directed to comply the order within one month from the date of receipt of this order failing which the Complainant is entitled to get 12% interest from the whole sum.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 5^th day of October 2017.

Date of Filing:09.05.2017.

PRESIDENT : Sd/-

MEMBER : Sd/-

MEMBER : Sd/-

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witnesses for the complainant:

PW1. Sankarankutty P.E Complainant.

Witness for the Opposite Parties :

OPW1. Balu. M. Executive, Legal, Star Health.

Exhibits for the complainant:

A1. Copy of Lawyer notice. dt;29.12.2016.

A2(1) Postal Receipt. dt:30.12.2016.

A2(2) Postal Receipt. dt:30.12.2016.

A3 (3 Nos) Acknowledgment.

A4. Reply Notice. dt:24.01.2017.

A5. Copy of Final IP Bill Detail. dt:19.08.2016.

Exhibits for the opposite Parties:

B1. Copy of Star Senior Citizens Red Carpet Insurance – Proposal. dt:09.09.2013.

B2(1) Copy of Senior Citizens Red Carpet Health Insurance Policy.

B2(2) Police Conditions.

B3. Copy of Claim Form- Part A

B4. Copy of Discharge summary.

B5. Copy of Bill assessment Sheet.