The case of complainant is as follows:

            The complainant and his family were insured with the respondent company under Pravasi Suraksha Kudumba Aroggya Scheme. The policy period was 5/6/01 to 4/6/06. Being the subscribers of policy they are eligible to get treatment expenses. While so on 10/2/04 complainant was consulted Dr.RamMohan in West Fort Hospital, Thrissur in concern with throat disease and taken medicines but not completely cured.   So the complainant was admitted on 1/3/04and discharged on 2/3/04 itself. He had incurred treatment expense for Rs.7,156.90 and approached the respondent company with all documents to get the policy benefits. But the company refused to accept the claim so the complainant put an application on 11/6/04 to the respondent and the respondent sent a reply dated 17/6/04 with untrue matters. The view of the respondent that the complainant is eligible to get only Rs.1172/- is wrong. According to the complainant he is eligible for the entire amount claimed. Non allowing of that amount shows service deficiency of respondent and hence this complaint.

 

            2. The averments in the counter are as follows:

The respondent admits that complainant had been insured with this respondent under Pravasi Suraksha Kudumba Aroggya Scheme certificate No.760306470180342 with the respondent for a period from 5/6/2001 to 4/6/2006 subject to the terms, conditions, exception and limitations stipulated therein. As per clause VII Exclusion : The company shall not be liable to make payment under this scheme in respect of expenses whatsoever incurred by or for any insured person in connection with or in respect of charges incurred at hospital or nursing home primarily for diagnostic, X-Ray or Laboratory examination not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at hospital or nursing home. The respondent specifically denies the allegation in the petition that the complainant had spent Rs.7156.90 for the alleged treatment. It is true that the complainant has preferred a claim under the above policy for the treatment of cough and Asthmatic Bronchitis. The complainant had also submitted bills amounting to Rs.72256.90. The complainant was hospitalized on 1/3/04. The amount claimed under the policy to the tune of Rs.7156/- with 12% interest is highly excessive, arbitrary and not in tune with reality. Moreover the amount of Rs.10000 claimed for mental agony and Rs.200/- as compensation is not at all sustainable. The amount claimed is not to be considered as it is not in tune with reality. The petitioner is not at all entitled to get such an exorbitant amount as compensation. In fact this claim is not in accordance with the policy and therefore is liable to be rejected. The respondent has intimated the complainant this matter and also sent loss voucher for Rs.1172/-. There is no deficiency in service. The amount claimed by the complainant is highly excessive and the respondent is not liable to pay it. Hence dismiss the complaint.

 

            3. The points for consideration are:

1) Is there any deficiency in service ?

2) If so reliefs and costs ?

 

            4. The evidence consists of Exhibits P1 and P2 and Exhibits R1 to R10.

 

            5. Points : The complaint is filed to get insurance policy benefits from the respondent company. The case of complainant is that he being a policy holder of Pravasi

Suraksha Kudumba Aroggya Scheme is eligible to get treatment expenses from the respondent company. According to the complainant on 10/2/04 the complainant had consulted Dr.RamMohan the doctor working at West Fort Hospital, Thrissur in concern with throat disease and taken medicines but was not cured. So the complainant was admitted on 1/3/04 and treated and discharged on 2/3/04. He had treatment expenses of Rs.7156/-and preferred claim to the company, but was rejected by the company. According to the company since the complainant was hospitalized on 1/3/04 for the treatment of cough and asthmatic bronchitis the respondents allowed all expenses incurred in connection with the disease and excluding the expenses which were not connected with the diseases for which he was hospitalized on 1/3/04.

 

            6. Exhibits P1 and P2 are the documents produced on the part of complainant. According to the complainant he is entitled to get all the medical expenses he had met. The rejection of the claim by the company is deficiency in service. The complainant is a policy holder of Pravasi Suraksha Kudumba Aroggya Scheme and the period of policy was from 5/6/01 to 4/6/06 and the treatment was within the policy period. So he is entitled to get the policy benefits. The rejection of the claim was on flimsy grounds. The complainant had consulted Dr.RamMohan on 10/2/04 in concern with throat disease and was not cured fully and hospitalized on 1/3/04. As per Exhibit R3 the date of first consultation for ‘this’ disease shown as 10/2/04 and the awareness of the existence of the disease stated is 4 weeks. The nature of disease shown as right vocal cord paralysis under investigation with Asthmatic Bronchitis. So at that time also i.e. on 10/2/04 at the time of first consultation, the complainant was suffering from asthmatic bronchitis. So it is clear that the tests done after the consultation on 10/2/04 were related to the illness and not for a separate one as stated by the respondent company. As per Exhibit R7 the claim was rejected for the reason that the expenses which were not connected with the diseases for which he was hospitalized on 1/3/04 were excluded. But this version of the respondent company is not genuine and cannot be accepted.   In Exhibit R6 discharge summary the final diagnosis shows that right vocal cord paralysis under investigation with Asthmatic Bronchitis. So at the time of first consultation also he had such disease. The history and physical finding as stated in Exhibit R6 shows that this is a case of irritant cough – 4 weeks. The date of first consultation on 10/2/04 will come under this 4 weeks and rejection of the claim is found not on genuine reason.

 

            7. The version of the company is that as per clause VII exclusion the company shall not be liable to make payment under this scheme in respect of expenses whatsoever incurred by or for any insured person in connection with or in respect of charges incurred at hospital or nursing home primarily for diagnostic, X-Ray or Laboratory examination not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at hospital or nursing home. But in the case this exclusion clause not applicable. In this case the main reason stated by the company in repudiating the claim is that the expenses which are claiming were not connected with the disease for which the complainant was hospitalized on 1/3/04. Exhibit P2 clearly shows in definitions that relevant medical expenses incurred during the period up to 30 days prior to hospitalization on disease/illness/injury sustained will be considered as part of claim of that particular hospitalization. Thus the complainant is entitled for pre-hospitalization expenses up to 30 days prior to hospital. The date of admission was on 1/3/04 and the first consultation was on 10/2/04. The period is within 30 days and the complainant is definitely entitled for the expenses he had met.

 

            8. Exhibit R9 series are the bills of complainant and produced by the respondent and shows Rs.6,233.95 as the expenses. Exhibit R2 shows the details of treatment expenses and there were writings seen to be made by the respondent company and they calculated only Rs.1171.90 is payable. So the bill amount is seen to be admitted by them. The ‘not payable’ endorsement was due to the reason stated and discussed above and for the above discussed reasons it is found that the complainant is entitled for Rs.7256.90. Moreover the respondent company has no case that he had not incurred this amount. They only contended that the complainant is not eligible to get the entire amount.

 

            9. In the result the complaint is allowed and the respondent company is directed to pay Rs.6,234/- (Rupees Six thousand two hundred and thirty four only) to the complainant as the medical expenses and Rs.2000/- (Rupees Two thousand only) as compensation and Rs.500/- (Rupees Five hundred only) as costs. Comply the order within two months.

 

            Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open Forum this the 20^th day of February 2009.