This is a complaint filed under Section 12 of Consumer Protection Act for an order directing the opposite party to pay `25,000 as claim amount and `2000 as compensation.

          Complainant’s case in brief is as follows :  Complainant is a Medi-Claim Policy Holder under 1^st opposite party, ever since in 2002, without break.  While taking the policy he was made believe that his treatment expenditure up to `50,000 will be covered as per the above policy.  On 27.03.2011 he was hospitalized at GEM Hospital at Coimbatore for Laparoscopic Herioplasty.  He was there in the hospital from 27.03.2011 to 29.03.2011.  He had incurred treatment expenditure amounting to `41,200 over and above the expense of by standard and so on.  A claim was forwarded in due course but there was negative response.  On conveying serious objection it was reconsidered and they issued a DD for an amount of `16,200.  However the remaining claim `25,000 had been rejected without any reason.  The letter of 2^nd opposite party is silent regarding his reason for rejection of the bulk of his claim.   There was an offer of free medical check up within the scheme over and above the no claim bonus already accrued, for not making any claim for more than 5 years.  Lawyer notice was issued to 1^st opposite party with a copy to 2^nd opposite party.  They sent no reply.  Hence this complaint.

          Pursuant to the notice opposite party made appearance.   1^st opposite party filed version but 2^nd opposite party kept silent.  1^st opposite party contended as follows :  The opposite party has considered the claim of the complainant and has allowed `16,200 against the claim for `41,200.  That is the amount for which complainant is entitled as per the Insurance Policy condition No.2.10 towards the item No.10 of the schedule of payment for specified surgery for hermia-inguinal.  The allegation that he was made believe that he had been entitled for the medical expenses upto a limit of `50,000 are not true. The claim was forwarded to 2^nd opposite party M/s. T.T.K. Health Service who is the third party administration as defined under clause 3.8 of the policy condition.  Hence they are proper persons to process the claim.  The averment that opposite party had not replied to the lawyer notice dated 15.11.11 is totally false.  1^st opposite party had sent a registered reply dated 15.12.2011.  Since opposite party has already paid the sum insured as per policy condition complainant is not entitled for any relief. There is no deficiency of service on the part of opposite party.  Hence to dismiss the complaint.

          On the above pleadings the following issues have been taken for consideration:

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

2.           Whether the complainant is entitled for any remedy as prayed for?

3.           Relief and cost.

The evidence consists of the oral testimony of PW1, Ext.A1 to A7 on the side of the complainant and the oral testimony of DW1 and Ext.B1,B2  on the side of 1^st opposite party.

Issues No.1 to 3:

          It is an admitted case that complainant is the policy holder under 1^st opposite party.  Complainant submitted a claim for `41,200 and the opposite party allowed only an amount of `16,200.  Complainant thus filed this complaint for the balance amount. Opposite party contended that complainant is entitled for a reimbursement upto a limit as per clause 2.10 of the policy conditions for a sum of `16,200 which is the sum assured.  As per clause 2.9 of the policy conditions the total amount payable under the policy during the period of insurance will in no case exceed the sum insured and will be subjected to the limits shown in the schedule in clause 2.10 or actuals whichever is less.

          Complainant case is that he is entitled for the full reimbursement of the medical expenses for the treatment he had undergone from 27.03.2011 to 29.03.11.  Complainant had been holding the policy right from 2002.  Ext.A7 is the medi claim insurance policy produced by complainant.  DW1 in  his cross examination admitted that Ext.A7 is the policy condition of 2002.  Opposite party contended that the old Mediclaim policy was in existence only upto 2007 and complainant renewed the policy as Janatha Mediclaim policy along with its new conditions.

          Complainant adduced evidence that he had been continuing the policy from 2002 onwards.  He can also stated that at the time of taking the policy he was made believe that he would be allowed medical expenses up to an amount of `50,000.  But the supporting document Ext.A7 does not show any such condition.  No other evidence is made available to see that complainant is entitled for such an amount as medical expenses.  Note on Schedule 1 specifically stated that “Company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured per person mentioned in the schedule”.  Opposite party has taken the specific contention that as per clause 2.9 of the policy conditions the total amount payable under the policy during the period of insurance will in no case exceed the sum insured and will be subjected to the limits shown in the schedule in clause 2.10 or actuals whichever is less.  Thus opposite party further contended that complainant is entitled only for a re-imbursement upto a limit as per clause 2.10 of the policy conditions for a sum of `16,200 which is the sum assured and hence the same is allowed and given to complainant.  Ext.A7 is produced by complainant.  The note for schedule 1 in Ext.A7 made it clear that company’s liability shall not exceed the sum insured per person mentioned in the schedule. Opposite party’s contention based on the clause 2.9 of the conditions Ext.B1 is similar to that of the above stated note.  Complainant has no dispute with respect to the sum insured.  Hence the present position is that complainant has already received the sum insured `16,700. 

          On going through the evidence it can be seen that complainant could not succeeded in establishing his case.  He is miserably failed to place enough materials before the Forum so as to establish that he is entitled for any amount over and above the sum insured.  Hence we have no hesitation to say that complainant is not entitled for the relief prayed in the complaint.  Thus the issues 1 to 3 are answered against the complainant.

          In the result, the complaint is dismissed.

                                  Sd/-                     Sd/-         Sd/-

                           President                Member      Member

APPENDIX

Exhibits for the Complainant

 A1. Copy of the mediclaim policy issued by OP

A2.  Copy of the lawyer notice sent to OP.

A3 & 4.  Acknowledgement Cards.

A5. Discharge  summary issued from GEM Hospital & Research Centre

A6. copy of the letter sent by 1^st OP to 2^nd OP & complainant

A7. Medi claim insurance policy(Schedule) issued by 1^st OP

Exhibits for the opposite parties

B1.  Janata Mediclaim policy Conditions.

B2. Copy of the reply notice sent to complainant

Witness examined for the complainant

PW1.  Complainant

Witness examined for opposite party

DW1.  Suresh Babu

                                                                      /forwarded by order/

                                                                   SENIOR SUPERINTENDENT