By. Smt. Beena. M, Member:

            This is a complaint filed under section 12 of the Consumer Protection Act 1986.

2.  The complainant’s case in brief is as follows:-

                     The complaint is filed by the complainant under section 12 of the Consumer Protection Act.   The case of the complainant is that the Opposite Party

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is the insurance company and the complainant is the policy holder of the Opposite Party.  The policy number is No.7622073416280000008.   As per the policy the Complainant and his family members are entitled to get the medical expenses from the Opposite Party.  The Complainant’s son Roshan Justus undergone an operation and he was admitted in Malabar Institute of Medical Science-Aster MIMS Hospital at Kozhikode on 30.08.2017, surgery was conducted on 31.08.2017 and discharged on 01.09.2017. Altogether he has incurred an amount of RS.44,523/-for the treatment.  The Opposite Party paid Rs.13,903/-. The Complainant remitted the balance amount of Rs.30,620/- as bill amount at the time of discharge.  The Complainant approached the Opposite Party and submitted a claim for an amount of Rs.30,620/-, but the Opposite Party reimbursed only Rs.1,417/- . The Complainant approached the Opposite Party for the balance amount but the Opposite Party abstained from making payment of the balance amount. The act of the Opposite party is unfair trade practice and there is deficiency of service on the part of the Opposite Party. The Complainant is put to great mental agony and financial loss due to the act of the Opposite Party. The Opposite Party is liable to pay the balance amount and compensation.  Hence the complaint is filed for getting relief.

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            3. Notice was served to the  Opposite Party , he entered appearance, filed version and contested the case.

The Opposite Party admitted that the policy was issued in favour of the Complainant covering the period form 26.02.2017 to 25.02.2018. The period of previous policy was from 26.02.2016 to 25.02.2017 and the sum assured was Rs.1,00,000/-. As per the policy condition the ailment called ‘Adenoid Hypertrophy’ is not covered. Whereas the patient Roshan Justus had complaints of Nasal Block and Mouth breathing since 8 months prior to the date of admission.  The patient was admitted in the Hospital on 30.08.2017.  The aliment started during January 2017 i.e. during the period of the previous policy. Hence the Complainant is entitled to get the amount based on the sum insured of the previous policy i.e. Rs.1,00,000/-.  As per clause No.3.1(a) Room Rent including but not limited to boarding and nursing expenses, actually incurred or 1% of the sum insured per day, whichever is less.   This opposite party has already paid the amount of Rs.13,903/- to the hospital as per entitled room rent category. Still the complainant submitted a claim for Rs.30,620/- out of that Rs.685/-  claimed for Medicine charge was allowed, Medicine charge claim for Rs.1,108/- was not allowed since the bill was a duplicate copy. The claim for medicine Rs.732/- was

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allowed and towards special procedure charge claim of Rs.28,095/-maximum amount was paid to the hospital as per entitled room rent category. Hence the maximum amount payable to the complainant was Rs.1,417/- this amount was paid by this Opposite Party to the Complainant and the Complainant accepted the amount as full and final satisfaction of the claim.  Therefore the Complainant is not entitled to get any more amount and is not entitled to get compensation as claimed.  Hence prayed for dismissal of complaint against this Opposite Party with cost.

4.  On perusal of complaint, version and documents the Forum raised the following points for consideration:-

1. Whether the Complainant is entitled to get any amount from the Opposite Party?
2. Whether there is any act of unfair trade practice and deficiency of service happened from the part of Opposite Party?
3. Whether the Complainant is entitled to get any amount as compensation?
4. Relief and cost.

5. Point No. 1 to 3 :-  For the sake of convenience and brevity points No.1 to 3 are considered together.

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6.  To substantiate the case of the complainant he produced 3 items of documents along with the complaint.  Complainant filed chief affidavit in which he has affirmed and explained all the averments stated in the complaint and he  was examined as PW-1.  He also produced documents which are marked as Ext. A1 to A4 and Ext.X1 series. Ext.A1 is the copy of the bills issued by the hospital, Ext.A2 is the  copy of payment receipt, Ext. A3 is the copy of claim form and Ext. A4 is the cashless claim approval letter.

7. From the side of the Opposite Party the Divisional Manager filed detailed counter proof affidavit in which he has affirmed and explained all the contentions raised in their version in detail and examined as OPW-1 and  documents produced by him  were marked as Ext. B1 and B2. Ext.B1 is the policy for the year 2016-2017 and Ext. B2 is the policy for the year 2017-2018.

            8. We have gone through the contents of the affidavit filed and documents produced from both sides. This complaint is based on a mediclaim policy issued by the Opposite Party. The policy is admitted, the claim submitted and rejection of that claim is also admitted by the Opposite Party. On going through the Ext. A4

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document, medical computation sheet disallowed medical expenses shown as Rs.28,949/-. On the perusal of the Ext.A4 document it can be seen that the opposite party not properly computed the things. The refusal to pay the full cost of anesthesia and surgeons charge is wrong. On verifying the policy conditions as per Cls No.3.1.(c), 3.1(d) the opposite party is liable to pay full amount for the Anesthetist charge and surgeon charge but opposite party denied to pay full amount.  The rejection of full payment towards the anesthesia and surgeons charges is not justifiable. Other rejected things are common things.  Hence the complainant is entitled to get Rs.9,316/- towards the balance amount of Anesthetist charge and surgeon charge from the opposite party. As the insurer, the Opposite Party is having an obligation to consider the Complainant’s claims properly. Here the Opposite Party failed to consider the claim of the Complainant properly.

9. From the above facts the Forum finds that there is deficiency in service on the opposite party’s part. Hence points No.1 to 4 are found in favour of the complainant.   Considering the circumstances of the case the Complainant is entitled to get compensation and cost of the case from the Opposite Party.  

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10. Point No.4:- Since, we found point No.1 to 3 against the opposite party, the complainant is  entitled to get relief and cost.

            In the result, the complaint is partly allowed and the Opposite Party is directed to pay Rs.9,316/- (Rupees Nine Thousand Three Hundred and Sixteen)  as further claim amount and Rs.5,000/-(Rupees Five Thousand) as compensation and Rs.3,000/-(Rupees Three Thousand) towards the cost to the Complainant within one month from the date of receipt of the order.   If the Opposite Party fails to comply this order the Complainant can execute the order through due process of law at the expenses of the Opposite Party.

  Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 18^th day of March 2020.

Date of Filing: 18.04.2018.

                                                                                                PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

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APPENDIX.

Witness for the complainant:-

PW1.              Jestus.                                                Complainant.

Witness for the Opposite Party:-

OPW1.          K. Somanathan.                              Divisonal Manager.

Exhibits for the complainant:

A1.                  Copy of the Bill.                                                      Dt:01.09.2017.

A2.                  Copy of Payment Receipt.                                   Dt:01.09.2017.

A3.                  Copy of Claim Form.

A4.                  Copy of Cashless Claim Approval Letter.

X1(a).             Claim Form.

X1(b).                        Claim Form Part B.

X1(c).             Copy of Aadhar Card.

X1(d).                        Cancelled Cheque.

X1(e).             Copy of Letter.                                                        Dt:25.09.2017.                  

X1(f).             Prescription.                                                            Dt:08.09.2017.

X1(g).             Copy of Discharge Summary.

X1(h).                        Payment Receipt.

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X1(i).              Pharmacy Bill.                                                         Dt:01.09.2017.

X1(j).              Pharmacy Bill.                                                         Dt:08.09.2017.

X1(k).             Pharmacy Bill.                                                         Dt:08.09.2017.

X1(l).              Copy of Policy Schedule.                                     

X1(m).           Copy of Collection Receipt cum Adjustment Voucher.

X1(n).                        Copy of Reimbursement Claim Approval Letter.

X1(o).                        Copy of Mediclaim Computation Sheet.

X1(p).                        Copy of  letter.                                                        Dt:06.10.2017.

X1(q).                        Discharge Certificate.

X1(r ).                        Copy of Letter.                                                        Dt:06.10.2017.

Exhibits for the opposite party:-

B1.                  Copy of Policy (26.02.2017 to 25.02.2018).

B2.                  Copy of Policy (26.02.2016 to 25.02.2017).

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

/True Copy/

Sd/-

     SENIOR SUPERINTENDENT,

                                                                         CDRF, WAYANAD.