Per Sri A. Hazarath Rao,  President:-

        The complainant filed this complaint under section 12 of the Consumer Protection Act seeking Rs.75,294.66 ps., together with interest @24% p.a.,; Rs.15,000/- as compensation towards mental agony and suffering and for costs.

2.   In brief averments of the complaint are these:

        The complainant took mediclaim policy from the opposite party and is renewing every year and the latest policy is from 11-11-10 to 10-11-11 vide policy No.550507/48/10/8500000719.  The complainant on 31-10-11 went Manipal Hospital, Tadepalli with a complaint of pain in left knee joint.   The complainant underwent ECHO and ECG as per the advice of Manipal Hospital.   After verifying ECHO and ECG reports doctors suspected heart ailment and advised to get angiogram.  Accordingly, complainant spent Rs.11,503 towards medical expenses during hospitalization from 31-10-11 to 02-11-11.  The complainant approached M/s Apollo hospital, Madras for second opinion.  M/s Apollo hospital at Madras took angiogram again on 05-11-11.   Doctors at M/s Apollo hospital, Madras advised CABG surgery.   On 07-11-11 the opposite party gave authorization letter to M/s Apollo hospital, Madras guarantying the payment and it was valid for admission within three days from the issuance of letter on the expiry of the policy which ever is earlier.   The complainant joined in M/s Apollo hospital, Madras on 08-11-11.   Some clinical examination was done during 08-11-11 to 12-11-11.   M/s Apollo hospital, Madras advised the complainant that the doctor who conducted surgery went abroad for attending medical seminar and he was discharged on 12-11-11 with a recommendation of early CABG surgery and prescribed medicines.   On the date of discharge the complainant paid Rs.63,791.66 ps.  The concerned doctor of M/s Apollo hospital, Madras returned from abroad on                   01-12-11 and conducted surgery on the basis of investigation done during 08-11-11 to 12-11-11.   The opposite party paid Rs.1,42,000/- on a renewed policy from 10-11-11 to 11-11-12.  But the opposite party repudiated the claim of Rs.63,791.66 ps incurred by the complainant during hospitalization in M/s Apollo hospital, Madras during 08-11-11 to 12-11-11 and Rs.11,503/- during the hospitalization in M/s Manipal Hospital during 31-10-11 to 02-11-11.   Clinical investigation is a part and parcel of the surgery and without clinical investigation one cannot go for surgery.   The complainant suffered a lot mentally and financially due to the above act of the opposite party and it amounted to deficiency of service.   The complaint therefore be allowed.

3.   The contention of the opposite party in brief is thus:

The complainant obtained mediclaim policy from the opposite party covering the period from 11-11-10 to 10-11-11. The complainant made a claim for Rs.11,503/- for the charges incurred during 31-10-11 to 02-11-11 in M/s Manipal Super Speciality Hospital, Vijayawada.   The complainant got discharged from M/s Manipal hospital on                       02-11-11 without taking any further treatment for undergoing any operation/surgery.   As the complainant did not take treatment in                     M/s Manipal Super Speciality Hospital,  Vijayawada   the opposite party sent e-mail requesting the said hospital authorities to cancel the said cashless facility.   So far second claim is concerned after going through record it was found that the case of complainant was a case of old silent MI, Angiographically two vessel disease, Hypertension and obstructive sleep apnoea and that the complainant got admitted in Apollo hospital, Chennai on 08-11-11 for Coronary Artery Bypass Surgery (CABG).   In fact the Good Health Plan Limited, TP Claims Agency has given cashless facility for an amount of Rs.88,050/-.   Later on 12-11-11, the final bill along with the discharge summary was received and wherein it is found that surgery has not been performed but the insured was investigated for fitness for surgery.                                The complainant submitted the claim form dt. 18-11-11 for          Rs.65,303-46 ps.  The TPA claims agency observed that a sleep study was done which revealed mild obstructive sleep aponea.   Since obstructive sleep aponea is due to obesity, which is not covered under the policy conditions as it is not a disease.   (Exclusion-4.19 which reads as follows: Treatment for obesity for condition arising there from (including morbid obesity) and any other weight control program/services/supplies.   Further it is observed that it is a planed admission and all the investigations done during hospitalization could have been done on out patient basis except for sleep study.   As obesity does not meet the definition of the disease as mentioned above, it’s consequences are also not payable.  Hence sleep study is also not covered.   Hence cashless facility is also cancelled.   It is not correct that the doctor went abroad without conducting CABG surgery during hospitalization from 08-01-11 to 12-11-11.  The complainant underwent investigation for fitness only and some medicines were prescribed and discharged.   As such the admission for investigation and evaluation is excluded from the purview of policy under exclusion clause 4.10.   In any manner the claims made by the complainant for Rs.11,503/- during the hospitalization in M/s Manipal hospital for the period 31-10-11 to 02-11-11 and Rs.63,791.66 ps towards hospitalization in M/s Apollo hospital, Madras during 08-11-11 to 12-11-11 are not admissible.   Hence repudiation of both the claims are legal, valid and binding.   The opposite party did not commit any deficiency of service.   The complainant is not entitled to claim any amount for mental agony and legal expenses and repudiation is justified.

4.  Exs.A-1 to A-4 and Ex.B-1 to B-8 on behalf of complainant and opposite party were marked respectively.

5.   Now the points for consideration in this complaint are:

1. Whether the repudiation of claim by the opposite party for        Rs.11,503/- is justifiable and if not amounted to deficiency       of     service?

1. Whether the repudiation of claim by the opposite party for Rs.63,791.66 ps during hospitalization from 08-11-11 to                    12-11-11 is justifiable and if not amounted to deficiency of service.
2. Whether the complainant is entitled to compensation?
3. To what relief?

6.   Admitted facts:-

1. The complainant is taking mediclaim policy since 12 years                         from the opposite party.   The last is from 11-11-10 to                 10-11-11.

1. The opposite party on 07-11-11 gave authorization letter to M/s Apollo hospital, Madras guarantying the payment of Rs.88,050/-.
2. The insured amount is Rs.1,25,000/- (Ex.A-2).
3. The opposite party repudiated the claim of the complainant for Rs.11,503/- and Rs.65,303/- (Ex.A-3 and A-4).

7.   POINT No.1:    In Ex.A-2 at the top the following was mentioned:

          “Authorisation letter to the hospital for the treatment and guarantee of payment, valid for admission within 3 days from issuance of this letter of the expiry of the current policy which ever is earlier.”

The complainant approached M/s Manipal hospital, Tadepalli with a complaint of pain in left knee joint.  It is not the case of the complainant that he took treatment for the said ailment.   Ex.B-1 is the terms and conditions of mediclaim insurance policy.  Clause 4.10 of Ex.B-1 says that expenses incurred primarily for evaluation/diagnostic purposes not followed by active treatment during hospitalization is excluded.   Since the complainant did not undergo any treatment for pain in left knee joint, the repudiation of claim by the opposite party is justifiable in our considered opinion.  We therefore answer this point in favour of opposite party.

8. POINT No.2:   Under Ex.A-2 (=B5) the opposite party guaranteed payment of Rs.88,050/-.   Even on Ex.A-2 (=B5) the following was mentioned:

        “Authorisation letter to the hospital for the treatment and guarantee of payment, valid for admission within 3 days from issuance of this letter of the expiry of the current policy which ever is earlier.”

9.     Again the opposite party relied on Ex.B-7 discharge summary of M/s Apollo hospital relating to the complainant.   The complainant was diagnosed as suffering from hypertension, obesity, S/P right TUR- October-2010, Left OA, Coronary Artery Disease-old ASM, (silent) Angiographically two vessel disease (05.11.2011), Moderate left ventricular dysfunction, OSA; with a recommendation of early CABG surgery.

10.    Clause 4.19 excluded treatment for obesity or condition arising there from that including morbid obesity and any other weight control programme/services.   It is not the obesity of complainant alone that caused coronary artery disease as seen from Ex.B-7.   Clause 4.10 of Ex.B-1 no where prescribed time limit for active treatment followed by diagnosis.   Clinical observations/investigations is a part of surgery or other treatment as rightly contended by the complainant.  The complainant claimed Rs.65,303.46 ps towards investigation charges and treatment in M/s Apollo hospital, Madras during 08-11-11 to                 12-11-11 (Ex.A-3).   When terms and conditions of the policy did not prescribe any minimum time limit for the treatment followed by investigation the opposite party prescribing three days time limit either under Ex.A-2 or B-3 or B-5 in our considered opinion is not fair and repudiating the claim though followed by treatment at a later date (even in a fortnight) amounted to deficiency of service.   The opposite party is therefore liable to reimburse Rs.65,303/-.   We therefore answer this point in favour of the complainant.      

11.  POINT No.3:-    The complainant claimed Rs.15,000/- as damages towards mental agony and suffering.   It is an admitted fact that the opposite party paid treatment expenses.   Under those circumstances, awarding Rs.2,000/- as damages in our considered opinion will meet ends of justice.    We therefore answer this point accordingly.

12.  POINT No.4:-   In view of above findings, in the result the complaint is partly allowed as indicated below:

1. The opposite party is directed to pay Rs.65,303/- (Rupees sixty five thousand three hundred and three only) to the complainant together with interest @9% p.a., from the date of complaint till realisation.
2. The opposite party is directed to pay Rs.2,000/- (Rupees two thousand only) as damages and Rs.1,000/- (Rupees one thousand only) towards costs to the complainant.

3.     The amounts ordered above shall be paid within a period          of six weeks from the date of receipt of the copy of                   the order.

          Typed to my dictation by Junior Stenographer, corrected by me and pronounced in the open Forum dated this the 9^th of January, 2013.

          MEMBER                                                            PRESIDENT

APPENDIX OF EVIDENCE

DOCUMENTS MARKED

For Complainant  :

For Opposite Party  :

                                                                                                                                                                                                                 PRESIDENT