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 Rs.5,039/- being the claim amount and Rs.10,000/- as compensation and cost of the proceedings.

2. Complaint in brief:- The Complainant took Health Insurance from the 1^st Opposite party on 08.03.2006 and renewed periodically. On 10.10.2013, the complainant was admitted at St. Vincent Hospital Mananthavady due to fever for 3 days. After 3 days, the Complainant was discharged. The complainant informed the company through Agent about Admission. The Complainant send the claim form after 10 days to 2^nd Opposite party. But the company repudiated the claim and gave repudiation letter to the Complainant on 17.01.2014. The reason for the repudiation are that the Complainant failed to submit relevant documents with respect to the treatment, and for the treatment of Complainant, hospitalization was not required. The act of the Opposite party is nothing but 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. 2^nd Opposite party not appeared and 2^nd Opposite Party is set exparte. In the version of 1^st Opposite Party, 1^st Opposite Party stated that the Complainant was submitted a claim on account of fever with Pancy to penia and 2^nd Opposite Party processed the claim as per section 12(d)(ii) of Health Insurance Regulations Act 2013 and repudiated the claim. Since clinical presentation does not necessitated the inpatient care. Hospitalization was not justified and 1^st Opposite Party denies all other allegations of the Complainant.

4. On perusal of complaint, documents, version the forum raised the following points for considerations.

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 documents are marked as Exts.A1 to A4. The 1^st Opposite Party also filed proof affidavit and is examined as OPW1, and documents are marked as Exts.B1 to B3. Ext.A1 is the policy and Ext.A2 is the claim information, Ext.A3 series are the medical reports for medicalim. Ext.B1 is the policy, and Ext.B2 is the repudiation letter. Ext.B3 is the claim form and Ext.B4 series are medical reports. The reason stated in Ext.B2 is that for the Complainant's treatment, clinical presentation does not necessitate the inpatient care. On perusal of entire evidences, and documents, the Forum analysed that the doctor who treats the patient decides whether treatment requires admission of the patient or not. In this case, the doctor decided to admit the patient for treatment. So the inpatient treatment in this case is justified. The repudiation of in this case is deficiency of service from the part of Opposite parties.

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.50,391/- (Rupees Fifty thousand Three hundred and Ninety One) only being the treatment expenses ie claim amount and the 1^st Opposite Party is also directed to pay Rs.2,000/- (Rupees Two thousand) only as compensation and Rs.1,000/- (Rupees One thousand) only as cost of the proceedings. 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 thereafter.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 8^th day of August 2015.

Date of Filing:23.02.2015.

PRESIDENT :Sd/-

MEMBER :Sd/-

/True Copy/

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witness for the complainant:

PW1. Augustine Complainant.

Witness for the Opposite Party:

OPW1. Naveen Palliyath Branch Manager, United India Insurance Co. Ltd.,

Exhibits for the complainant

A1. Copy of Individual Health Insurance Policy.

A2. Copy of Detailed Claim Information.

A3 Series (19 Pages) Copy of Medical Report.

A4. Copy of Application.

Exhibits for the opposite Party.

B1. Copy of Individual Health Insurance Policy – 2010.

B2. Copy of Claim Status. dt:10.05.2014.

B3 series Copy of Mediclaim Insurance Policy Claim Form and other documents.

(13 in numbers)