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. 5,518/- for the Hospital expenses, Rs.1,000/- as notice charges, Rs.2,730/- policy charge with interest of 12% per annum for the date of denial till payment and to pay Rs.50,000/- as compensation and cost of the proceedings.

2. Complaint in brief:- The Complainant had taken Family Medicare Policy for the period from 12.04.2012 to 11.04.2013. An amount of Rs.2,730/- was paid as premium and the Opposite party No.4 had issued to policy certificate accordingly. As per condition, all the family members are covered in the policy. While so the son of Complainant named Blessin Benny caught severe stomach pain and he is admitted on 06.03.2013 in Assumption Hospital at Sulthan Bathery and discharged on 11.03.2013. The Complainant had spent an amount of Rs.5,518 for the said treatment. At the time of hospitalisation itself the Complainant had submitted the claim through the hospital authority to the Opposite party for getting the insurance amount for meeting all the treatment expenses along with the claim form. As per term, the Complainant is entitled to get all the expense directly to the hospital. On 08.03.2013 the 2^nd Opposite Party send intimation to Hospital stating that they denied cash less benefit to the Complainant. Denial is un reasonable. The Complainant is a coolie worker. Act of Opposite party amounts to deficiency of service. Aggrieved by this the complaint is filed.

3. On receipt of complaint, notices were issued to Opposite Parties and notices were served to Opposite parties on 04.02.2014. Opposite parties No.1 to 3 did not appear in court and Opposite parties No.1 to 3 were set exparte. 4^th Opposite Party appeared before the Forum and filed version. In the version, 4^th Opposite party contended that the Complainant had not submitted any claim form for reimbursement of the treatment expenses for his son. On primary scrutiny of documents for cashless benefit for hospitalisation is denied since as per the available denial destroy, the treatment protocol too does not necessitate in patient stay and management. 4^th Opposite Party denied all other material allegation in the petition.

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 he is examined as PW1 and Exts.A1 to A7 is marked. Opposite Parties No.1 to 3 are exparte and 4^th Opposite party filed proof affidavit and 4^th Opposite party is examined as OPW1. As per order, the Assumption Hospital produced treatment records and are marked as Exts.X1 to X7. The 4^th Opposite party admitted the treatment of the son of Complainant and admission in the Hospital. The case of 4^th Opposite Party is that for the treatment of the son of Complainant, no admission in the hospital is necessary and hence cashless benefit is denied. On going through the Hospital records, it is seen that the son of Complainant is admitted in the Hospital for treatment as per the direction of the treating doctor. Whether the disease is simple or major and whether it requires admission etc are to be decided by the treating doctor.

6. In the cross examination of OPW1, OPW1 deposed that the policy holder ie the Complainant have the right for cashless benefit as per policy conditions and also admitted that the 4^th Opposite party received intimation for cashless benefit. It is up to the doctor to decide whether admission is necessary or not in a case. Stomach ache may come due to several reasons. So it needs further test and treatment for which admission is necessary. So the Forum is of the opinion that denial of cashless benefit to the son the Complainant is a deficiency of service from the part of Opposite Parties. Point No.1 is found accordingly.

7. Point No.2:- Since point No.1 is found against the Opposite parties, Opposite Parties No.1 to 4 are liable to pay cost and compensation to the Complainant.

In the result, complaint is partly allowed and Opposite Party No.1 to 4 are directed to pay Rs.5,518/- (Rupees Five thousand Five hundred and Eighteen) only for the hospital expense and Rs.2,000/- (Rupees Two thousand) only as policy charge with 12% interest from the date of denial till payment to the Complainant. The Opposite parties are also directed to pay Rs.10,000/- (Rupees Ten thousand) only as compensation and Rs.5,000/- (Rupees Five thousand) only as cost of the proceedings. Opposite parties No.1 to 4 are jointly and severally liable to pay the above amounts 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 5^th day of January 2015.

Date of filing:23.01.2014.

PRESIDENT : Sd/-

MEMBER : Sd/-

MEMBER : Sd/-

/True copy/

Sd/-

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witness for the complainant:

PW1. Benni Complainant.

Witness for the Opposite Parties:

OPW1. Sajeevan Branch Manager, United India Insurance

Company, Sulthan Bathery.

Exhibits for the complainant:

A1. Family Medicare Policy.

A2. List of Network Provider of Kerala.

A3. Copy of Letter. dt:08.03.2013.

A4. Discharge Summary.

A5. Hospital Bills. dt:13.03.2013.

A6. Copy of Letter.

A7(a) Postal Receipt dt:25.04.2013.

A7(b) Acknowledgment.

A7(c) Postal Receipt. dt:25.04.2013.

A7(d) Acknowledgment.

X1. Prescription dt:07.03.2013.

X2. I.P. Case Sheet.

X3. O.P. Additional Sheet.

X4. Doctor's Order & Progress Notes.

X5. (T.P.R) Graphic Sheet.

X6. Nurse's Medication Record.

X7. Investigation Report.

Exhibits for the opposite Parties.

Nil.