By. Smt. Renimol Mathew, Member:

The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to get reimbursement of claim amounts in connection with the hospitalization of the complainant, her husband and child.

2. Brief of the complaint:- The complainants are the beneficiaries of opposite parties Family Health Optima Insurance revised policy as per Policy No.P/181315/01/2017/000760. Opposite party offered cashless treatment or entire reimbursement of hospital expenses to the complainant. The 1^st complainant is the principal insured and 2^nd and 3^rd complainant are her husband and child. The 1^st complainant was admitted and treated at Fathima Matha Mission Hospital, Kalpetta from 30-09-2016 to 10-10-2016, the 1^st complainant has intimated the claim to opposite party immediately after the admission and registered the claim as claim No.CLI/2017/181315/0239522. The opposite party have offered cashless treatment, the 1^st complainant has given the copies of bills to opposite party but against the policy conditions opposite party has not provided a cash less treatment and the 1^st complainant was compelled to pay the hospital bill of Rs.14,854/- without any valid reason opposite party has informed that the claim was repudiated and in addition to that opposite party has harassed 1^st complainant and her 6 months old child mentally in front of others without considering as a lady. The 2^nd complainant was admitted in St Vincent's Hospital, Mananthavady and treated therein as an impatient from 06.10.2016 10-10-2016, the 2^nd complainant has intimated the claim to opposite party immediately after the admission and registered the claim as claim No.CLI/2017/181315/0249570 and opposite party have also offered cashless treatment, but against the policy conditions opposite party has not provided a cash less treatment and 2^nd complainant was compelled to pay hospital bill of Rs.9,379.35/-. The 2^nd complainant has given copies of all the medical bills to opposite party and opposite party has told the 2^nd complainant that the claim was under the process and requested time for payment and believing the words of opposite party the 2^nd complainant paid the bill amount, but the opposite party has not paid the amount and in between that 2^nd complainant has approached at opposite party's office several times but by saying lame excuses opposite party delayed the payment. The 3^rd complainant is the minor daughter of 2^nd complainant and she was admitted in St Vincent's Hospital, Mananthavady and treated therein from 20.11.2016 to 24.11.2016, the 2^nd complainant has intimated the claim to opposite party immediately after the admission of 3^rd complainant and opposite party has registered the claim as claim No. CLI/2017/181315/0311339 and opposite party have also offered cashless treatment to her, but against the policy conditions opposite party has not provided a cash less treatment to her and 2nd complainant was compelled to pay Rs.7895/-towards the hospital bill. The 2^nd complainant has given copies of all the medical bills of 3^rd complainant to opposite party and opposite party has told 2^nd complainant that the claim was under the process and requested time for payment and believing upon the words of opposite party 2^nd complainant has paid the bill amount, but the opposite party has not paid the amount and in-between that 2^nd complainant has approached at opposite party's office several times but by saying lame excuses opposite party delayed the payment. Hence filed this complaint.

3. On receipt of notice opposite parties entered and written version filed stating that the complainant had registered three claims in policy No.P/181315/01/2017/000760. In Claim No.CLI/2017/181315/0239522 the proposer, the 1^st complainant was admitted at Fathima Matha Mission Hospital on 30.09.2016 and had taken treatment for severe Nasal Bleeding, fever and cough. The company received a pre-authorization request from the hospital for extending the cashless facility. The company on 01-10-2016 had requested the hospital to submit the medical records of the In Patient admission of the proposer Anumol and the plan of treatment. But the hospital had not forwarded even the discharge summary so as to know the line of treatment for deciding the claim on merits. Since the Opposite patty did not receive the sufficient records to decide the admissibility of claim the cashless facility was denied and informed the same to the hospital on 05-10-2016 stating INFORMATION INSUFFICIENT - ETIOLOGY NOT GIVEN. It is submitted that in the denial letter, the opposite party had specifically stated that a claim form is sent herewith which may be duly completed and submitted to us along with all medical documents. However, the complainants had not complied with the said request. In Claim No.CLl/2017/181315/0249570, the husband of the proposer, the 2^nd complainant (Mr. Minesh Kumar) had taken treatment for Follicular Tonsillitis with LRTI at St.Vincent's Hospital on 06-10-2016 and the Company received a pre-authorization request from the hospital for extending cashless facility. As per the terms and conditions of the policy, diseases of ENT are excluded for a period of first two years as per Exclusion Clause No.3 of the policy. Hence the Opposite party Company had rejected the cashless facility and informed to the hospital on 10-10-2016. It is submitted that in the denial letter, the opposite party had specifically stated that a claim form is sent herewith which may be duly completed and submitted to us along with all medical documents. However, the complainants had not complied with the said request. In claim No.CLI/2017/181315/311339, the daughter of the Proposer, Nandana Minesh, the third Complainant had taken treatment for Follicular Tonsillitis on 21-11-2016 and the Company received a pre-authorization request from the hospital for extending cashless facility. As per the terms and conditions of the policy, diseases of ENT are excluded for a period of first two years as per Exclusion Clause No.3 of the policy. Hence the Opposite party Company had repudiated the claim which was informed to the hospital on 21-11-2016. It is submitted that in the denial letter, the opposite party had specifically stated that a claim form is sent herewith which may be duly completed and submitted to us along with all medical documents. However, the complainants had not complied with the said request. As per the Exclusion No.3 of the policy it is stated that "During the first two years of continuous operation of Insurance cover any expenses on Cataract, disease of the vitreous and Retina, Glaucoma, Diseases of ENT, Mastoidectomy, Tympanoplasty, Stapedectomy, Disease Related to Thyroid etc are excluded for the first two years of inception of the policy. Since the illness of the 2^nd and 3^rd complainant falls within the two year exclusion clause of the policy, the opposite party denied the cashless facility. It is further stated that the complainant had not submitted any claim with documents/bills to these opposite parties at any point of time. Thus the claim has not been repudiated and hence there is no cause of action for this complaint at all. On this ground alone the case has to be dismissed in limine.

4. It is further submitted that as per the terms and conditions of the policy, even the cashless facility was rejected, the complainant is always at his will to submit a completed claim form along with related documents. It is submitted that from the 5^th month onwards, the complainants has been claiming for the treatments undergone by them both as cashless and reimbursement and they have received a total of 12 claims so far under the policy. The opposite party is unnecessary dragged into the litigation without submitting claim form with supporting documents, hence there is no deficiency of service on the part of opposite party No.1.

5. Subsequently opposite party No.2 has impleaded and version filed stating that 1^st complainant was admitted in the 2nd Opposite Party Hospital on 30.09.2016 and was discharged on 10.10.16 is admitted by this Opposite Party. It is also admitted that the 1^st complainant had paid an amount of Rs.14,854/- towards the hospital bill. Except these facts all other averments made in this Paragraph is not pertaining to this opposite party. There was no deficiency of service or unfair trade practice on the part of this opposite party in treating the complainant No.1 in the above case. This opposite party is made a party in the above case without any reason and there is no cause of action to make this opposite party as a party in the complainant. So the above case is bad for misjoinder of parties. Since there was no deficiency of service this Opposite Party is not liable to pay any compensation to the complainant No.1 in the above case as alleged by the complainant. The complainants No.2 and 3 were not treated in the 2^nd opposite Party hospital at any time. There is no bonafides in the above complainant. The above complainant is frivolous, vexatious and devoid of truth or bonafides. There is no negligence or deficiency of service on the part of this opposite party. The complainants are not entitled to get any relief from this opposite party as prayed for in the complaint. This Opposite Party had taken all steps to help the complainant for getting the treatment charge from the Opposite Party No.1. This Opposite Party is unnecessarily impleaded in the complaint merely on the basis of inferences and assumptions for undue financial advantage of the complainant. There is no cause of action against this Opposite Party. There is no specific pleadings against this Opposite Party also. Hence prayed to dismiss the complaint.

6. Complainant filed proof affidavit and examined as PW1. Ext.A1 to A9 documents were marked. Opposite party No.1 also adduced evidence and examined as OPW1 and Ext.B1 to B17 documents were marked. Wherein Ext.B4, B5, B9, B12 and B13 were marked subject to proof. Ext.A1 is the Authorization Letter dated 16.01.2017. Ext.A2 series are the Bills (12 numbers). Ext.A3 is the Copy of Discharge summary of 1^st complainant. Ext.A4 is the Denial of Pre-authorization for cashless treatment. Ext.A5 series are the Bills (3 numbers). Ext.A6 is the Discharge/Referral Card. Ext.A7 series are the bills (2 numbers). Ext.A8 is the Discharge/Referral Card. Ext.A9(1) is the Registered Legal Notice. Ext.A9(2) is the Acknowledgment Card. Ext.B1 is the copy of Proposal form. Ext.B2 is the Family Health Optima Insurance Policy Schedule. Ext.B3 is the Request for cashless hospitalization for medical insurance policy. Ext.B4 is the Query on pre-authorization dated 01.10.2016. Ext.B5 is the Denial of Pre-authorization for cashless treatment dated 05.10.2016. Ext.B6 is the Pre-authorization Request Form. Ext.B7 is the Query of Pre-authorization dated 07.10.2016. Ext.B8 is the copy of hospital record. Ext.B9 is the Denial of Pre-authorization for cashless treatment dated 10.10.2016. Ext.B10 is the Pre-authorization Request form. Ext.B11 is the copy of Hospital Records. Ext.B12 is the Rejection of Pre-authorization for cashless treatment dated 21.11.2016. Ext.B13 is the Reply Notice dated 24.01.2017.

7. On perusal of complaint, version and document 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.

8. Point No.1:- Heard the parties. Admittedly complainants are the beneficiaries of opposite party party No.1's Health Insurance Policy vide No.P/181315/01/2017/000760. Complainant registered three claims to opposite party No.1 they rejected the claim. In reply opposite party No.1 argued that the complainants had registered 3 claims under the policy. In claim No.CLI/2017/181315/0239522 the 1^st insured had taken treatment for nasal bleeding, fever and cough. The company received a pre-authorization request from the hospital for extending the cashless facility. The company on 01-10-2016 had requested the hospital to submit the medical records of the In Patient admission of the proposer Anumol and the plan of treatment. But the' hospital had not forwarded even the discharge summary so as to know the line of treatment for deciding the claim on merits. Since the Opposite patty did not receive the sufficient records to decide the admissibility of claim the cashless facility was denied and informed the same to the hospital on 05-10-2016 stating INFORMATION INSUFFICIENT - ETIOLOGY NOT GIVEN. In the denial letter, the opposite party had specifically stated that a claim form is sent herewith which may be duly completed and submitted to us along with all medical documents. However, the complainants had not complied with the said request. In Claim No.CLl/2017/181315/0249570, the husband of the proposer, the 2^nd complainant (Mr. Minesh Kumar) had taken treatment for Follicular Tonsillitis with LRTI at St.Vincent's Hospital on 06-10-2016 and the Company received a pre-authorization request from the hospital for extending cashless facility. As per the terms and conditions of the policy, diseases of ENT are excluded for a period of first two years as per Exclusion Clause No.3 of the policy. Hence the Opposite party Company had rejected the cashless facility and informed to the hospital on 10-10-2016. In the denial letter, the opposite party had specifically stated that a claim form is sent herewith which may be duly completed and submitted to us along with all medical documents. However, the complainants had not complied with the said request. In claim No.CLI/2017/181315/311339, the daughter of the Proposer, Nandana Minesh, the third Complainant had taken treatment for Follicular Tonsillitis on 21-11-2016 and the Company received a pre-authorization request from the hospital for extending cashless facility but diseases of ENT are excluded for a period of first two years as per Exclusion Clause No.3 of the policy. Hence the Opposite party Company had rejected the cashless claim which was informed to the hospital on 21-11-2016. Opposite party further argued that as per the Exclusion No.3 of the policy it is stated that "During the first two years of continuous operation of Insurance cover any expenses on Cataract, disease of the vitreous and Retina, Glaucoma, Diseases of ENT, Mastoidectomy, Tympanoplasty, Stapedectomy, Disease Related to Thyroid etc are excluded for the first two years of inception of the policy. Since the illness of the 2^nd and 3^rd complainant falls within the two year exclusion clause of the policy, the opposite party denied the cashless facility. Thus the claim has not been repudiated and hence there is no cause of action for this complaint at all.

9. Opposite party further argued that in the 1^st claim even the cashless facility was rejected the complainant is always at his will to submit a completed claim form along with related documents. But in this case the complainant had not submitted any claim with documents or bill to the opposite party No.1 at any point of time. This claim has not been repudiated and there is no cause of action for this complaint.

10. On going through the evidences and records it appears that per-authorization request from the hospitals for extending cashless facility was rejected by the opposite party No.1 through Ext.B5, B9 and B12. Complainant had not submitted any claim with documents to the opposite party till this date instead filed this complaint by producing original bills and treatment records Ext.A1 to A8) before this Forum. Here the claim of the complainants are not been repudiated by opposite party No.1 and there is no cause of action for this complaint as contented by opposite party. Going through the merits of the claim. The 2^nd and 3^rd claims are denied for the reason that admittedly ''the treated illness of 2^nd and 3^rd complainants falls within the two year exclusion clause of the policy (Ext.B2). The 1^st inception of the policy was on 16.05.2015 the present illness was treated during October and November 2016. Regarding the 1^st claim, it is a genuine claim and admissible one and as a consumer of opposite party, complainant is entitled to get reimbursement of admissible claim amount in this claim from the opposite party. Complainant produced the relevant hospital bills and medical records before the Forum and opposite party No.1 has direct knowledge about these Et.A1 to A8 documents. Hence we opine that 1^st complainant is entitled to get reimbursement of claim amount in claim No.CLI/2017/181315/0239522 from opposite party No.1. 2^nd and 3^rd claim is not admissible since it falls under exclusion No.3 of Ext.B1. There is no allegation or prayers against opposite party No.2. Point No.1 is found accordingly.

11. Point No.2:- Since there is no deficiency of service proved against the opposite parties as alleged complainant is not entitled to get cost and compensation from the opposite parties. Point No.2 is decided accordingly.

In the result, the complaint is partly allowed and opposite party No.1 is directed to pay the claim amount of Rs.14,854/- (Rupees Fourteen Thousand Eight Hundred and Fifty Four) in claim No.CLI/2017/181315/0239522 to the 1^st complainant. Opposite party No.1 is also directed to take the original bills and related documents produced by the complainant from the Forum. No Order as to cost and compensation. This Order must be complied by the opposite party No.1 within 30 days from the date of receipt of this Order.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 16^th day of November 2017.

Date of Filing:16.01.2017.

PRESIDENT :Sd/-

MEMBER :Sd/-

MEMBER :Sd/-

/True Copy/

Sd/-

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witness for the complainant:-

PW1. Minesh Kumar. Factory Manager.

Witness for the Opposite Parties:-

OPW1. Balu. Executive, Legal, Star Health and Allied Insurance Co Ltd.

Exhibits for the complainant:

A1. Authorization Letter. Dt:16.01.2017.

A2(Series). Bills (12 numbers).

A3. Discharge Summary.

A4. Denial of Pre-authorization for cashless treatment. Dt:01.10.2016.

A5(Series). Bills(3 numbers).

A6. Discharge/Referral Card. Dt:24.04.2016.

A7(Series). Bills (2 numbers).

A8. Discharge/Referral Card. Dt:26.11.2016.

A9(1). Registered Legal Notice. Dt:27.01.2017.

A9(2). Acknowledgment Card.

Exhibits for the opposite parties:-

B1. Copy of Proposal Form.

B2. Copy of Family Health Optima Insurance policy schedule.

B3. Request for cashless hospitalization for medical insurance policy.

B4. Query on pre-authorization. Dt:01.10.2016.

B5. Denial of Pre-authorization for cashless treatment. Dt:05.10.2016.

B6. Pre-authorization Request Form.

B7. Query on pre-authorization. Dt:07.10.2016.

B8. Hospital Records(2 Pages).

B9. Denial of Pre-authorization for cashless treatment. Dt:10.10.2016.

B10. Pre-authorization Request Form.

B11. Hospital Records (7 pages).

B12. Rejection of Pre-authorization for cashless treatment dt:21.11.2016.

B13. Reply Notice. Dt:24.01.2017.

Sd/-

PRESIDENT, CDRF, WAYANAD.

a/-