C.K. Lekhamma, Member.

          The case of the complainant is as follows:

          The complainant is a health card holder of  the 3^rd opposite party.  The health card covering Rs. 1,00,000/- with effect from 02/09/2003 onwards.  The opposite parties No. 1 & 2 are an  authorized agent of the 3^rd opposite party. The complainant was hospitalized  at Krishna Hospital, Ernakulam for a surgery on 01/08/2008.    Thereafter the complainant has filed claim before the opposite parties.  But the opposite parties repudiated the claim. Complaint has filed  representation before the opposite parties but the same has not been considered till date. The complainant  contented that the denial of mediclaim by the opposite parties is illegal and arbitrary. Therefore, the complainant is before us seeking direction against  the opposite parties to direct the opposite parties to refund to the complainant, the amount of Rs. 31,330.00  towards the medical and other expenses along with interest incurred by him.

2. Version of the 3^rd opposite party.

The 3^rd opposite party has no knowledge about the complainant’s hospitalization as alleged in the complaint.  Neither the complainant nor the first and second  opposite party has informed the 3^rd opposite party about the claim of the complainant or its rejection or his grievances.  Hence the 3^rd opposite party does not admit the claim of the complainant and the allegations in the complaint.  The complainant has not filed any representation or complaint before the 3^rd opposite party.  The complainant has no complaint of deficiency in service on the part of the 3^rd opposite party.  There is no cause of action as alleged in the complaint.  The complainant has violated the policy conditions. The 3rd opposite party has not admit the statement of expenses, shown in the complaint.  The complainant has not entitled to get  the expenses for correspondence, traveling expenses  etc.

3. The complainant was examined as PW1 and Exts. A1 to A8 were marked. Opposite parties 1 and 2 remained absent. Neither oral  nor documentary evidence was adduced by the 3^rd opposite party.  Thereafter we have heard both sides.

4. The points that arose for our consideration are as follows:

i. Whether the complainant is entitled to get the insurance claim from the 3^rd opposite party?

ii. Compensation and costs if any

5. Points Nos. i & ii. There is no dispute with regard to the issuance of the policy and its validity  The only dispute raised by the 3^rd opposite party is that neither the complainant nor the 1^st or 2^nd opposite parties has informed them  about the claim of the complainant or its rejection or his grievances. And the complainant has not filed any representation before the 3^rd opposite party.

 It is pertinent to note that the 3^rd opposite party does not have a  case that the 1^st and 2^nd opposite parties are not their agents.  Admittedly 1^st and 2nd opposite parties  are the 3rd party administer of the 3^rd opposite party, who are authorized to process the claim applications of the insured.   Moreover Ext.A1 Health card issued by 3^rd opposite party in which logo of the opposite parties 1 and  2 is affixed.  Ext. A7 is a  letter issued by the 2^nd opposite party.  In Ext. A7 it is specifically mentioned the “Branch office”  UNITED  “Branch Office: UNITED INDIA INSURANCE COMPANY LTD-011100 SUDERSHAN BLDG, OLD NO.14.” In accordance of  the evidence we found that opposite parties 1 and 2 are the agents of the 3^rd opposite party.  Hence 3^rd opposite party is bound by all dealings done by them with regard to  the claim of the complainant.  There is no merit in the contention of the 3^rd opposite party that the complainant has not submitted application before them is untenable

The reason for repudiation as per Ext. A5 dated 04-08-2008 is as follows:

 “ FRESH POLICY POSSIBILITY OF LONGSTANDING FATHOLOGY CANNOT BE RULED OUT.  HENCE CASHLESS NOT POSSIBLE CAN  BE CONSIDERED FOR CLAIMS AS PER POLICY TERMS AND CONDITIONS”. After Ext. A5 the 3^rd opposite party has  issued Ext. A7 letter dated 18-11-2008 requesting the  treating doctor’s clarification to the effect that  whether surgery was done under LA/GA”   In Ext. A7 itself treated doctor mentioned that the surgery was done under Local Anesthesia. It is evident from   Ext. A4, copy of the letter dated 26-11-2008 caused by  the complainant to the 2^nd opposite party  that the complainant sent clarification certificate issued by the treated doctor as requested by the 2^nd opposite party.  In Ext. A2 discharge summary and Ext. A8 copy of the request for additional information, go to show that the  endorsement of the doctor and  no where it is stated,  that the disease of the complainant  was pre-existing.

 In the aforementioned reasons we are of the view that the complainant  is entitled to get the mediclaim insurance from the 3^rd opposite party. In the facts and circumstances of the case we are not ordering any compensation and costs of the proceedings. 

 6. In short, we allow the complaint and direct that the 3^rd opposite party shall  pay the medi-claim insurance of the complainant as per norms.

The  above said order shall be complied with within a period of one month   from the date of receipt of a copy of this order

Pronounced in the open Forum on this the 30^th day of June 2011