By Smt. Saji Mathew, Member:

The gist of the complaint is as follows:- The Complainant is a member of Vakery Ksheerolpadaka Sahakaran Sangam and has joined the Ksheera Karshaka Arogya Suraksha Paddathi. This is an insurance project launched by the 1^st and 3^rd Opposite Party. As he was a member of the project he has undergone treatment for urological disease from 25.09.2009.  He was hospitalized in P.V.S Hospital on 29.9.2009. Surgery was done on 30.9.2009. He stayed in the hospital till 02.10.2009. Then the Complainant laid claim for the medical bill before the 1^st Opposite Party. No action was taken by the Opposite Parties to disburse the insurance amount to the complaint. Hence the Complainant prays for an order directing the Opposite Parties to pay Rs. 25,000/- as the insurance amount and Rs.5,000/- as compensation.

2. The Opposite Parties filed version. The 1^st Opposite Party admitted the policy and the submission of claim by the Complainant. In processing the claim, the 1^st Opposite Party asked the Complainant for some clarification and the Complainant did not give any. The medical report accompanied by the claim form was silent regarding the probable duration of illness. So, the 1^st Opposite Party was unable to process the claim. If satisfactory clarification is supplemented and if claim is payable as per policy terms and condition, the Opposite Party's liability will come to Rs.9,375/-. If the disease was pre-existing, the Opposite Party is no liable to pay any amount to the Complainant. There is no deficiency in service on the part of the 1^st Opposite Party and they pray for the dismissed of the complaint.

3. The 2^nd Opposite Party admits the membership of the Complainant in the sangam and the claim before the 1^st Opposite Party. He is aware of the fact of illness and treatment of the Complainant. The 3^rd Opposite Party stated in their version that they are unnecessary party in the case. They had issued a circular containing the details and eligibility criteria for enrolling in the scheme as well as entitlement of the benefits of the scheme and only accordingly the members are enrolled in the scheme and are entitled to the benefits of the scheme. If any amount is found payable to the complainant, the 1^st Opposite Party is liable to pay that.

4. The Complainant was examined as PW1 and documents were marked as Ext.A1 and X1 on the side of the Complainant. No oral evidence was adduced on the side of the Opposite Parties. Documents were marked as Exts.B1 to B5 on the side of the Opposite Parties.

5. The matters to be decided are as follows:-

1. Whether there is any deficiency in service on the side of the Opposite Parties?

2. Whether the Complainant is entitled for any relief?

6. Point No.1:- In this case the fact of the Complainant's disease and treatment are admitted by the Opposite Parties. The only objection for paying the insurance amount is that the doctors certificate is silent regarding the duration of illness. The doctors certificate is not produced before the Forum. The Complainant has duly answered all questions in the claim form. In Ext.B1, the claim form date of commencement of disease is stated as 29.9.2009. The Opposite Party could not prove that the disease was pre-existing. Hence point No.1 is found against the 1^st Opposite Party.

7. Point No.2:- The 1^st Opposite Party has contented the payable amount as Rs.9,375/-. This amount tally with the policy condition (Ext.B4). The 1^st Opposite Party is liable to pay this amount to the complainant.

Hence, the 1^st Opposite Party is directed to pay the Complainant an amount of Rs. 9,375/- (Rupees Nine thousand Three hundred and Seventy Five only) with 30 days the receipt of this order. The 1^st Opposite Party is also directed to pay Rs.1,000/- (Rupees One thousand only) also to the Complainant as cost of this case. The Opposite Party has to pay interest on the ordered amount Rs.10,375/- at rate of 10% per annum from the date of this order till payment.

Pronounced in open Forum on this the day of 31^st December 2010.

Date of filing:08.06.2010.

PRESIDENT: Sd/-

MEMBER : Sd/-

MEMBER : Sd/-

A P P E N D I X

Witness for the Complainant:

PW1. Manoj. Complainant.

Witness for the Opposite Parties:

Nil.

Exhibits for the Complainant:

A1. Copy of Discharge Summary.

X1. Case Sheet.

Exhibits for the Opposite Parties:

B1. Claim Form.

B2. Copy of Letter. dt:11.11.2009.

B3. Universal Health Insurance Policy Schedule.

B4. Universal Health Insurance Policy.

B5. Copy of Misc. claim scrutiny Form.