By Sri. Chandran Alachery, Member:

The complaint is filed under section 12 of the Consumer Protection Act for an order directing the 1^st Opposite party to pay Rs.26,483/- being the balance amount of claim and also to pay Rs.50,000/- as compensation and cost of the proceedings.

2. Complaint in brief:- The Complainant is the holder of Family Health Optima Insurance Policy conducted by the 1^st Opposite party. The policy number is P/181314/01/2015/001102. The Complainant, his wife and two children were covered under the policy. During the validity of policy, the wife of the Complainant has suffered swelling as abdominal wall, Abdominal diversification and weakness, the complainant has taken her to the 2^nd Opposite Party hospital where 3^rd Opposite party treated the Complainant. The complainant's wife has been admitted on 18.12.2014 on the advice of 3^rd Opposite party for a minor surgery. The 2^nd Opposite party assured cashless benefit also. After surgery, the Complainant has been discharged on 26.12.2014. The total treatment expenses is Rs.45,483/-. The Agent of 1^st Opposite party collected all records and bills and obtained signature from the Complainant. But not paid the claim amount. After the Complainant in grievance cell, the Opposite Party sent a DD for an amount of Rs.19,000/- to the Complainant. This amount do not cover the entire treatment expenses. It is a clear deficiency of service from the part of Opposite parties. Aggrieved by this, the complaint is filed.

3. On receipt of complaint, notices were issued to opposite parties and 1^st Opposite party appeared before the Forum and filed version. Opposite party No.2 and 3 not appeared before the Forum even if notice served to Opposite Party No. 2 and 3 and hence Opposite Party No.2 and 3 were set exparte. In the version of 1^st opposite party, the 1^st Opposite party stated that the Complainant has accepted settlement of the claim by signing the discharge voucher without any protest. Once the petition has received the amount unconditionally and got the cheque encashed the petitioner ceases to be consumer. The privity of contract come to an end and the petition is not maintainable. There was no deficiency of service from the part of 1^st opposite party. The hospital records of the wife of Complainant shows that the diagnosis as abdominal distention/obesity. Since treatment of obesity is not covered under the policy and the documents were insufficient to decide the merits of the case. The past history of the patient was recorded as h/o LSCS first 14 years and second LSCS 6 years back. On an independent medical opinion, the Opposite Party​ confirmed that abdominal diversification of recti is a complication of previous LSCS and abdominal plasty will come under cosmetic correction treatment. Hence the claim is repudiated as per clause 7 and 14 of the policy. The Complainant again applied for reconsideration with treating doctor certificate. The doctor certified that the treatment is not purely for cosmetic purpose. Hence considering the situation, the claim is settled as non- standard basis.

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

1. Whether there is 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 Exts.A1 to A7. The 1^st Opposite party also filed proof affidavit and 1^st Opposite party is examined as OPW1 and documents are marked as Exts.B1 to B9. Here the 1^st Opposite party settled the claim on non standard basis by considering the reconsideration application of complainant with medical certificate from treating doctor. Here the treating doctor certified that the present condition is due to sequel of previous pregnancy and surgical procedure and is not purely for cosmetic purpose. The total expenses for the treatment incurred by the Complainant is Rs.45,483/-. Out of which the Opposite party paid Rs.19,000/- to the Complainant. Now the Complainant prayed for an order directing the 1^st Opposite party to pay Rs.26,483/- as balance amount of claim. Since the surgical procedure done by the treating doctor is not only for cosmetic purpose, the Forum is of the opine that allowing half of the prayer amount is just and proper in this case. The Forum found that not allowing reasonable amount of claim to the Complainant by the 1^st Opposite party is a deficiency of service from their part. Point No.1 is found accordingly.  The Forum found that Opposite party No.2 and 3 are not liable to compensate the Complainant.

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

In the result, the complaint is partly allowed and the 1^st Opposite party is directed to pay Rs.13,000/- (Rupees Thirteen thousand) only to the Complainant towards treatment expenses to the Complainant. The 1^st Opposite party is also directed to pay Rs.1,000/- (Rupees One thousand) only as cost and compensation to the Complainant. The 1^st Opposite party shall comply the order within 30 days from the date of receipt of this order failing which the Complainant is entitled to get 12% interest for the whole sum.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Forum on this the 10^th day of December 2015.

Date of Filing:01.07.2015.

PRESIDENT :Sd/-

MEMBER :Sd/-

MEMBER :Sd/-

/True Copy/

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witness for the complainant:

PW1. Bimal Kumar. M.A Complainant.

Witness for the Opposite Parties:

OPW1. Mrudula. Executive, Legal dept

Star health Insurance Co. Ltd.

Exhibits for the complainant:

A1. Copy of Family Health Optima Insurance Policy – Schedule

A2. Discharge Summary

A3. Copy of Letter.

A4. Copy of Letter. dt:07.04.2015.

A5. Copy of Letter. dt:01.06.2015.

A6. Letter. dt:16.06.2015.

A7. Copy of Letter. dt:25.04.2015.

Exhibits for the opposite Parties.

B1. Authorisation Letter. dt:26.09.2015.

B2. Family Health Optima Insurance Plan.

B3. Family Health Optima Insurance Policy- Schedule.

B4. Proposal Form

B5. Copy of Discharge Summary

B6(1) Claim Form- Part-A.

B6(2) Claim Form – Part-B. dt:27.12.2014.

B7 Copy of Letter. dt:15.01.2015.

B8. Discharge Voucher. dt:25.04.2015.

B9. Letter. dt:14.05.2015.