By. Smt. Renimol Mathew, Member:

The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to get the claim amount with cost and compensation.

2. Brief of the complaint:- The complainant and his family members are beneficiaries of health insurance scheme conducted by opposite party. The son Master Basil Augustine of the insured hospitalized due to the dislocation of 2^nd toe while he was playing on school ground, immediately the teachers taken to Vinayaka Hospital, Sulthan Bathery and treated there as an inpatient from 04.07.2012 to 06.07.2012. The complainant spent Rs.2,639/- as medical expenses, Rs.2,000/- being the expenses of by standers, Rs.700/- as the transport to the hospital and return and Rs.150/- as the expenses of the preparing form for claim etc. Totaling Rs.5,489/-. The complainant submitted claim form before the opposite party but opposite party rejected the claim with a reason that the benefits will not be available for pre-existing disease as defined in the policy. According to complainant the rejection of claim by the opposite party is unfair trade practice. Hence filed this complaint.

3. Notice served to opposite party and they filed version. In the version, opposite party No.1 admitted that the complainant has taken a family health optima insurance policy from this opposite party on 04.06.2010 for sum insured of Rs.2 lakhs. The insured person's son was admitted at Vinayaka Hospital, Sulthan Bathery on 04.07.2012 for the treatment of compound dislocation of 2^nd toe and underwent reduction and suturing under local anaesthecia. After the treatment the complainant's child was discharged on 06.07.2012. Later on 25.07.2012 the opposite party received claim document with bills from the complainant. The complainant has stated that he had incurred total expense of Rs.5,489/- but complainant had submitted a signed claim form in which he has mentioned Rs.2,600/- as total expense. Opposite party again stated that they are ready and willing to settle the amount of Rs.1,964/- which is the maximum payable amount in this claim. Hence prayed to dismiss the complaint.

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

1. Whether there is any deficiency of service from the part of opposite party?

2. Relief and cost.

5. Point No.1:- Complainant filed affidavit and examined as PW1. Exts.A1 to A3 documents were marked. Opposite party also filed affidavit and examined as OPW1. Ext.B1 to B5 documents were also marked. Ext.A1 is the claim status. Ext.A2 is the letter dated 14.02.2013. Ext.A3 is the Discharge Card. Ext.B5 is the claim form filed and submitted by the complainant. As per claim form total amount of claim is of Rs.2,636/-. Opposite party stated that as per the terms and conditions of the policy they are ready to pay the claim amount. Hence complainant is entitled to get the amount as per the bills submitted before the opposite party. Point No.1 is found accordingly.

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

In the result, the complaint is partly allowed and the opposite party is directed to pay the claim amount of Rs.2,636/- (Rupees Two Thousand Six Hundred and Thirty Six) to the complainant along with compensation of Rs.2,000/- (Rupees Two Thousand) and Rs.2,000/- (Rupees Two Thousand) as cost of the proceedings. This Order must be complied by the opposite party 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 18^th day of June 2015.

Date of Filing:19.04.2013. PRESIDENT :Sd/-

MEMBER :Sd/-

/True Copy/

Sd/-

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witness for the complainant:-

PW1. Rajan. Complainant.

Witness for the Opposite Parties:-

OPW1. Manu Mohan. Claims Executive (Star Health).

Exhibits for the complainant:

A1. Claim Status.

A2. Acknowledgment Letter. Dt:14.02.2013.

A3. Discharge Card.

Exhibits for the opposite parties:-

B1. Authorization Letter. Dt:25.03.2015.

B2. Policy schedule and conditions.

B3. Copy of Discharge Card.

B4(Series). Medical Bills (8 Nos).

B5. Claim Form for Medical Insurance.

Sd/-

PRESIDENT, CDRF, WAYANAD.

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