By Sri. Chandran Alachery, Member:-

The complaint is filed under section 12 of the Consumer Protection Act for an order directing the Opposite parties to pay a sum of Rs.45,771/- being the remaining amount to be paid by the Opposite parties to the Complainant, to direct the Opposite parties to pay Rs.10,000/- towards compensation Rs.5,000/- towards mental agony and Rs.3,000/- towards cost of the proceedings.

2. Complaint in brief:- The Complainant is a mediclaim policy holder of Opposite parties. The Complainant joined in to the policy on 15.05.2015 and thereafter renewed in the year 2016. The sum assured is Rs.3,00,000/-. As per conditions in the policy, if the Complainant or his family members admitted in a hospital for more than 24 hrs, they are entitled to get pre-post hospitalisation expenses including room rent etc. The Complainant was admitted to the Baby Memorial Hospital on 10.07.2016 and discharged on 14.07.2016 due to compound fracture sustained to his right leg in an accidental fall. The Complainant spend more than Rs.87,540/- towards medical expenses. After the discharge, the Complainant submitted claim form along with original bills and reports. But without any reasons, the Opposite parties paid only Rs.41,769/- towards the full and final settlement of the claim. The Complainant received it under protest. The Complainant is entitled to get the full claim amount from the Opposite Parties and the Opposite Parties are liable to pay Rs.45,771/- towards the remaining amount. The act of Opposite Parties are deficiency of service and aggrieved by this, the complaint is filed.

3. On receipt of complaint, notices were issued to the Opposite parties and the Opposite parties appeared before the Forum and filed version. In the version of Opposite Parties, the Opposite parties admitted the treatment of Complainant at BMH Kozhikode. The complainant submitted claim form with documents for the reimbursement of Rs.93,390/-. The Opposite Parties after perusing the documents and bills had approved an amount of Rs.41,769/- as payable to the Complainant. A deduction of 11,621/- was made as per the terms and conditions. The Opposite parties paid Rs.41,769/- to the Complainant. The Opposite Parties had allowed the full admissible amount to the Complainant as per policy conditions in time. The Complainant is not entitled to get any balance amount and there is no deficiency of service from the part of Opposite Parties.

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 Ext.A1 to A5. Complainant's witness is examined as PW2. Opposite Parties also filed proof affidavit and the Opposite Party is examined as OPW1 and Exts.B1 to B6 are marked. Ext.A1 is the medical and pharmacy bills, Ext.A2 is the final IP bill details, Ext.A3 is the cash bill at BMH, Ext.A4 is the pharmacy bill from BMH, Ext.A5 is the policy, Ext.B1 is the final IP Bill details, Ext.B2 is the policy, Ext.B3 is the claim form. Ext.B4 is the discharge summary, Ext.B5 is the bill assessment sheet, Ext.B6 is the authorisation letter. The Opposite parties admitted the policy and the admission and treatment of complainant in the hospital. The Opposite Parties approved an amount of Rs.41,769/- to the Complainant. As per terms and conditions of policy, the Opposite Parties made a deduction of Rs.11,621/- also. As per calculation of 1^st Opposite Party, the net amount payable to the Complainant was Rs.81,769/-. Out of this net amount of Rs.81,769/-, the Opposite Parties made a deduction of Rs.40,000/- as hospital deduction. The Complainant challenged it and stated that the hospital made a deduction of only Rs.4,000/- from the final bill. To prove this aspect, the Complainant had cited a witness who is the Assistant General Manager, Baby Memorial Hospital Kozhikode. The witness is examined as PW2 and Ext.A6 document is marked. PW2 deposed that the hospital gave a deduction of Rs.4,000/- only from the bill amount. The Opposite Party by knowing the mistake, during trial expressed the willingness to pay the balance amount of Rs.36,000/- to the Complainant. Another contention raised by the Complainant is that the Opposite Parties not allowed the Anesthesia charges incured by the complainant as per Ext.A3 document. In the claim form, It is seen that Rs.4,500/- claimed towards Anaesthetic fee only. As per Ext.A3 original bill, it is seen that the anesthesia service charges collected is Rs.8,500/-. The Complainant not produced any document to show that the Complainant had claimed the amount as per Ext.A3 document. It is seen that the Opposite Parties had allowed Rs.4,500/- under this head which is the admissible amount. On perusing Ext.B1 final bill the Forum found that the handwritten portion of concession given, the amount written will cause confusion in the mind of those who read it. It seems that the amount is written as Rs.40,000/-. The Forum found that it is only a genuine mistake and not a deliberate mistake from the part of Opposite parties. It is up to the Complainant to clear the mistake by producing documents with respect to it to the Opposite parties. The Complainant produced Ext.A6 document before the Forum only. Therefore, on an over all evaluation of evidences and records, the Forum found that there is no deficiency of service from the Opposite Parties. Since the Opposite parties admitted the balance amount of Rs.36,000/- from the deduction amount, the Complainant is entitled to get Rs.36,000/- under this head from the Opposite parties. Point No.1 found accordingly.

6. Point No.2:- Since point No.1 is found against the Complainant, the complainant is not entitled to get cost and compensation.

In the result, the complaint is partly allowed and the 1^st and 2^nd Opposite Parties are directed to pay Rs.36,000/- (Rupees Thirty Six thousand) only to the Complainant towards balance treatment expenses. The 1^st and 2^nd Opposite Parties 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 28^th day of November 2017.

Date of Filing:02.12.2016.

PRESIDENT : Sd/-

MEMBER : Sd/-

MEMBER : Sd/-

/True copy/

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witnesses for the complainant:

PW1. Sasidharan. P. Complainant.

PW2. Mohanan. Asst. General Manager, Baby Memorial

Hospital, Kozhikode.

Witness for the Opposite Parties :

OPW1. Balu. Executive Legal, Star Health.

Exhibits for the complainant:

A1 series. Inpatient Pharmacy Credit Bill.

A2. Copy of Final IP Bill Detail.

A3. Bill. dt:11.07.2016.

A4. Copy of Pharmacy Bill. dt:14.07.2016.

A5. Policy Schedule.

A6. To Whomsoever It may concern. dt:12.04.2017.

Exhibits for the Opposite Parties:

B1. Copy of Final IP Bill Detail. dt:14.07.2016.

B2. Copy of Policy Schedule.

B3. Copy of Claim Form – Part A

B4. Copy of Discharge Summary.

B5. Copy of Bill Assessment Sheet – Member payment.

B6. Authorisation Letter. dt:19.09.2017.