By. Sri. K. Gheevarghese, President:-

The complaint filed against the opposite parties for the payment of the hospital charges of the insured.

2. The complaint in brief is as follows:- The complainant and other members in the family are the insured in a Mediclaim policy. The term of policy is three years and the sum assured was Rs.1,00,000/-. The premium that to be remitted by the complainant was Rs.3,450/- and the risk started from 10.10.2008 and expired on 06.10.2011. The complainant's wife was hospitalized for abdominal pain in 6^th opposite party's hospital which is the authorized hospital of the 1^st opposite party covering the risk of hospital treatments. The surgery for Hemorrhoids became inevitable as advised by Doctor who treated the patient. Upon enquiry it was informed the complainant that the 1^st opposite party has to meet the expenditure of surgery and other charges and upon the sanction of the amount by the Bajaj Allianz Life Insurance Company for the surgery and other treatments the patient was admitted in the hospital and surgery was conducted. At the time of admission Fathima Hospital collected from the complainant Rs.17,000/- as security and it was also informed at that time the security deposit would be refunded.

3. The complainant received a letter from the 5^th opposite party Fathima Matha Hospital, Calicut, that the insurance company has given only Rs.14,700/- to the hospital authorities and the balance amount of Rs.33,399/- to be paid directly by the complainant himself. The treatment availed by the patient, the insured was within the policy period of covering risk. The non payment of the hospital charges by the opposite parties is a deficiency in service. There may be an Order directing the opposite party No.1 to 5 to pay the hospital expenses of Rs.33,399/- and to return Rs.17,000/- to the complainant the amount deposited at the time of admission.

4. The opposite parties No.1 to 3 and 6 are set exparte.

5. Opposite party No.4 and 5 filed version in short it is as follows:- The 4^th opposite party was only a sales manager of the insurance company. This opposite party only informed the interested persons the terms and conditions of the policy. The complainant joined the policy upon fully agreeing the terms and conditions. When this opposite party was an employee of the insurance company acted upon the directions given by the higher authorities of the insurance company. The allegations of complainant is absolutely baseless. The inception to the policy of the complainant and other members was only after making out the entire terms and conditions. The claim and compensation are to be met by the company himself. The opposite party No.1,2 and 3 are responsible for it. This opposite party has no knowledge of the repudiation of the mediclaim of the complainant's wife and the treatment availed by them. The complaint is to be dismissed with cost.

6. The 5^th opposite party filed version in short it is as follows:- This opposite party acted as an agent of the company and the 4^th opposite party was the sales Manager during the period. The complainant took a mediclaim policy No.0110647918. The 5^th opposite party could realize that the claim of the complainant for hospital expenditure was repudiated by the insurance company. As an agent who worked under the company during the period is not liable to compensate and there is no deficiency in service on the part of this opposite party. The complaint is to be dismissed with cost.

7. The points in considerations are:-

1. Is there any deficiency in service on the part of the opposite parties in repudiation of the mediclaim policy?

2. Relief and Cost.

8. Points No.1 and 2:- The evidence in this case consist of the proof affidavit of the complainant. Exts.A1 to A8 are the documents produced. The personal evidence of the complainant is also considered in this case. Opposite parties No.4 and 5 have not tendered any evidence.

9. The policy document booklet dated 11.10.2008 is the Ext.A1. On perusal of the document it is clear that wife of the complainant was admitted in the 6^th opposite party's hospital and an emergent surgery for Hemorrhoids on 26.09.2011. The policy of Bajaj Allianz Family Care First covers risk of the expenditure for hospitalization and treatments. According to the complainant the 6^th opposite party collected from the complainant Rs.17,000/- on 26.09.2011 and the retail invoice was given to the complainant that is Ext.A3. The final diagnosis of the treatment as per the documents is Hemorrhoids. It is evidenced from the documents that the insurer paid only Rs.14,700/- out of the bill amount Rs.48,099/- the patient was requested to remit the balance amount Rs.33,399/- and a notice was sent in this effect by the hospital authorities. Opposite party No.4 was an employee during the period when the complainant and his family got access in to the policy. The 5^th opposite party acted only as an agent. The opposite parties No.4 and 5 are not personally liable to compensate the complainant. The opposite parties No.1 to 3 are the insurers and they are exparte in this case. In the absence of any adverse inferences from the insurers opposite parties No.1 to 3 is liable to pay the 6^th opposite party the hospital which made the expenditure for treatments and other charges. The 6^th opposite party hospital authority also directed to refund deposited amount of the complainant at the time of admission of patient.

In the result the complaint is partly allowed. The opposite parties No.1 to 3 are directed to pay Rs.33,399/- (Rupees Thirty Three Thousand Three Hundred and Ninety Nine Only) to hospital the 6^th opposite party. On receipt of the amount from the insurer the 6^th opposite party is also directed to pay back the complainant Rs.17,000/- ( Rupees Seventeen Thousand Only) collected at the time of admission of the patient. This is to be complied by the opposite parties No.1,2 ,3 and 6 within one month from the date of receipt of this Order.

Pronounced in Open Forum on this the day of 30^th May 2012.

Date of Filing:20.12.2011.