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.11,428/- with 12% interest from 30.10.2012 till payment being the expenses incurred for treatment and to pay Rs.20,000/- as compensation and cost of the proceedings.

2. Complaint in brief:- The Complainant took a family mediclaim policy from the Opposite Parties and the validity period is 18.09.2012 to 17.09.2013. As per the policy condition, if any member of the family is undergone treatment for at least 24 hrs as inpatient in any hospital, the treatment expenses will be paid by the Opposite Parties. On 21.10.2012, the Complainant due to sever stomach ache, admitted in Vinayaka Hospital, Sulthan Bathery and undergone treatment and discharged on 26.10.2012. The Complainant had to spent Rs.7,500/- as treatment expenses. The Complainant with all medical bills, submitted claim form with Opposite parties, but Opposite parties repudiated the claim on 08.11.2013 stating that the Complainant did not produce back treatment records. The Complainant on 08.09.2013 due to fever and body pain, admitted at the same hospital and discharged on 10.09.2013. The Complainant had to spent Rs.3,928/- as treatment expenses. The claim application of this 2^nd treatment also is repudiated by the Opposite Parties. The act of Opposite parties are 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 Opposite Parties appeared before the Forum and filed version. In the version of 1^st Opposite party, 1^st Opposite Party admitted that the Complainant took family mediclaim policy from 2^nd Opposite party through 1^st Opposite party, 1^st Opposite party is only an agent. There is no contract of insurance with 1^st Opposite party and the Complainant. There is no deficiency of service from the part of 1^st Opposite Party. In the version of 2^nd Opposite Party, Opposite parties stated that the Complaint on 21.10.2012 admitted at Vinayaka Hospital for treatment of Gastroduodenitis with enteritis and spent Rs.6,973/-. Considering the past medical condition, it is revealed that some past treatment records are to be verified and asked the Complainant to submit it. But no reply was there from the Complainant. Two reminders were also sent for which also no reply. So the 1^st claim is repudiated. Thereafter on 28.12.2012, the Complainant submitted a certificate of the treating doctor dated 17.02.2013 and as per which the Complainant was suffering from GERD since 2011 and the ailment is revealed that it is per-existing. The 2^nd Opposite party asked the Complainant to produce attested copies of indoor case papers of hospitalization including admission notes and daily progress note, original detailed discharge summary. The Complainant submitted incomplete papers. So the 2^nd claim is also repudiated. According to 2^nd Opposite party, there is no deficiency of service from the part of 2^nd Opposite Party.

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 A2 Opposite Party had not adduced any oral evidence. 2^nd Opposite Party filed documents without oral evidence and documents are marked as Exts.B1 to B10. Ext.A1 is the repudiation letter and Ext.A2 is also an intimation of claim closure. In Ext.A1, the 1^st reason is that claim is for the illness which has a specific two years of waiting period as per the policy and the policy start date is 18.09.2012. The 2^nd reason is that as per medical opinion and submitted documents, the need for hospitalisation is not established. In Ext.A2, the 2^nd Opposite party stated that inspite of reminder notices send on 16.11.2012, 01.12.2012 and 08.12.2012 the Complainant have not produced deficiency documents within a stipulated period. On perusal, it is found that the policy started as 18.09.2012 and its validity is up to 17.09.2013. The Complainant got admitted in Hospital on 21.10.2012 and second admission on 08.09.2013. So both admissions are within the validity period. To prove the policy condition that the waiting period of two years is there in the policy issued to the Complainant is not proved by producing the policy. It is up to the Opposite parties to prove these aspect. Regarding admission in hospital for the treatment of an illness, it is the treating doctor who decides whether admission is necessary or not. The treating doctor admitted the patient. Regarding pre-existing disease, the treating doctor issued Ext.B5 certificate without verifying the previous records of treatment. Ext.B5 did not contain that the doctor who treated the patient on 21.10.2012 and 08.09.2013 is the same doctor who treated the patient earlier. On what basis the doctor made such a comment in the certificate is not known. Ext.B5 is issued to the Opposite party by the doctor as 17.12.2013 which is five months after the treatment. No other document is produced by Opposite parties to prove that the Complainant have pre-existing disease. So by analysing all these available evidences and facts, the Forum is of the view that the Complainant is entitled to get medical reimbursement for the treatment done on 21.10.2012 and 08.09.2013. Moreover, the claim amount is very meager. So repudiating the 2 claims submitted by the the Complainant to 2^nd Opposite Party amounts to deficiency of service from the part of 2^nd Opposite Party. 1^st Opposite party is only an agent of 2^nd Opposite Party. Point No.1 is found accordingly.

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 2^nd Opposite Party is directed to pay Rs.7,500/- towards treatment expenses for treatment on 21.10.2012 and Rs.3,928/- towards treatment expenses for the treatment on 08.09.2013. The 2^nd Opposite party is directed to pay the above amounts with 12% interest from 08.09.2013 till payment. The 2^nd Opposite party is also directed to pay Rs.1,000/- (Rupees One thousand) only as compensation and Rs.1,000/- (Rupees One thousand) only as cost of the proceedings. The 2^nd Opposite Party shall comply the order 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 23^rd day of July 2015.

Date of Filing:04.12.2013.

PRESIDENT: Sd/-

MEMBER : Sd/-

MEMBER : Sd/-

/True Copy/

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witness for the complainant:

PW1. Biji Paul. Complainant.

PW2. Anilkumar. P.K. Asst. Surgeon & Medical Officer,

Primary Health centre, Noolpuzha.

Witness for the Opposite Parties:

Nil.

Exhibits for the complainant:

A1. Copy of Letter. dt:24.10.2013.

A2. Copy of Intimation of Claim Closure. dt:08.11.2013

Exhibits for the opposite Parties.

B1 series (6 in Nos) Receipt.

B2. Claim Form. dt:12.09.2013.

B3. Claim Form.

B4. Copy of Letter. dt:16.11.2012.

B5. Letter. dt:17.02.2013.

B6(2 in Nos) Claim Form

B7 series (7 in Nos.) Bill.

B8. Copy of Letter. dt:08.12.2012.

B9. Copy of Letter. dt:28.12.2012

B10. Copy of Letter. dt:16.11.2012