Sri. P. Satheesh Chandran Nair (President):

                   The complainant filed this petition u/s.12 of the C.P. Act 1986 for getting reliefs from the opposite parties.

                   2. The case of the complainant is as follows:  The complainant is an employee of Kerala Water Authority of Govt. of Kerala.  The complainant availed an insurance policy under the name and style ‘Family Health Plan’ with the opposite parties.  According to him, the said insurance scheme provide an insurance coverage up to Rs.3 lakhs for each year for him.  On 02.05.2016, the mother of the complainant Smt. Bhanumathi Amma was admitted in Life Care Clinic at Omalloor, as a result of fever and physical pain etc. etc. In that hospital one Dr. Vijayakumar treated the patient and at the time of testing the blood it is revealed that the mother is suffering liver cirrhosis.  As per the direction of the above said doctor the complainant took her mother to Muthoot Hospital, Pathanamthitta for a detailed liver scanning test.  It is contended that the concerned doctor attached to Muthoot Hospital also advised him for a further detailed treatment in a better hospital.  On 05.05.2016, the complainant’s mother was admitted in Amrita Hospital and treated for liver cirrhosis disease.  The complainant spent an amount of Rs.16,364/- for the treatment at Amrita Hosptial.  It is again contended that he preferred this hospital for treatment because of the belief that the opposite party approved this hospital for cashless treatment under this scheme.  The complainant approached the opposite party for the reimbursement of the expense incurred by him in Amrita Hospital the opposite party did not accept his request, hence this case.  He filed this complaint before this Forum for the reimbursement of the above said amount of Rs.16,364/-, cost, compensation etc.  This Forum entertained his complaint and issue notice to the opposite parties.  The opposite parties received notice and appeared before the Forum.

                   3. The version of the opposite parties are as follows:-  According to the opposite parties, the 2^nd opposite party has issued a ‘Family Health Plan’ policy to the complainant under which his mother is a beneficiary. It is again contended that the complainant’s mother was admitted in Amrita Hospital only for the purpose of investigation regarding her illness and for that so many tests were conducted but no treatment was carried out from that hospital.  Opposite parties stated that the above said policy is only for getting treatment expenses to the policy holders.  According to the opposite parties, the terms and conditions as per 4.11 is, “Charges incurred at Hospital or Nursing home primarily for Diagnosis, X-ray, or Laboratory examinations or other diagnostic studies not consists with or incidental to the diagnosis and treatment of positive existence of any ailment, sickness or injury for which confinement required at a hospital/Nursing Home”.  It is again contended that the outcome of the request for cashless treatment was duly informed to the complainant so that there is no deficiency in service on the part of the opposite parties.  Hence the opposite parties prayed to dismiss the complaint.

                   4. We peruse the complaint, version, records before us and framed the following issues:

1. Whether the opposite parties are committed any deficiency in service as alleged by the complainant?
2. Regarding relief and costs?

                   5. The case of the complainant consists of the proof affidavit filed in lieu of chief examination and Ext.A1 to A4.  Ext.A1 is the copy of medical report for scanning dated 04.05.2015 issued by Muthoot Medical Centre, Pathanamthitta.  Ext.A2 is the copy of discharge summary dated 07.05.2016 issued by Amrita Institute of Medical Sciences & Research Centre, Kochi.  Ext.A3 is the copy of bill dated 07.05.2016 for Rs.16,364/- issued by Amrita Institute of Medical Sciences & Research Centre, Kochi.  Ext.A4 is the copy of repudiation letter dated 07.05.2016 sent by opposite party to Amrita Institute of Medical Sciences.  The learned counsel appearing for the opposite parties cross-examined PW1 in this case but they did not adduce any oral or documentary evidence on their side.  When we look into the proof affidavit of PW1, it can be reveal that the proof affidavit is more or less as per the contention of his complaint.  It is deposed that he availed a ‘Family Health Plan’ insurance policy with the opposite parties and the premium amount was collected and remitted by his employer Kerala Water Authority.  When PW1’s mother suffered certain diseases he treated his mother at Omalloor Life Care Clinic and for a 2^nd opinion admitted at Muthoot Hospital, Pathanamthitta.  At last, it is revealed that his mother was suffering liver cirrhosis, for a better treatment she was admitted at Amrita Hospital, Kochi.  It is deposed that she was discharged from the said Amrita Hospital on 07.05.2016 and he paid an amount of Rs.16,364/- as medical expenses.  The opposite party repudiated his claim for the said amount on the ground that there is no treatment taken from Amrita Hospital.  After the closure of evidence, we heard both learned counsel appearing for the complainant and opposite parties. 

                   6. Point Nos.1 & 2:-  For the sake of convenience, we would like to consider Point No.1 and 2 together.  The main question to be considered in this case is whether the opposite parties have has committed any deficiency in service as alleged by the complainant.  It is admitted that the complainant is an insured of the opposite party and the opposite party is the insurer of the complainant.  It is also admitted that the mother of the complainant is comes under this scheme and the policy is for medical reimbursement.  If so, the next question to be considered is whether the complainant’s claim of medical reimbursement is comes under his policy or not.  It is true that as per the version of the opposite parties and at the time of cross-examination of PW1 opposite party has taken a strong case to the effect that the policy in question is not covered the present medical claim as per the terms and condition stated in Sec.4.11 of the policy conditions.  As per the terms and condition 4.11 of the said policy it is clear that the insurance company is not liable to pay any diagnise and treatment expenditure for positive existence of any ailment, sickness or injury for which confinement required at a hospital.  In this case, it is so clear that the mother of the complainant 1^st admitted in the hospital on 02.05.2016 for medical test and after the confirmation of the liver cirrhosis for a better treatment and consultation she was admitted in Amrita Hospital on 05.05.2016 and after the betterment she was discharged on 07.05.2016.  If it be so, there is no bar on the side of the opposite parties to grant medical imbursement to the complainant as per his request.  It is also to be find that the terms and condition seen in 4.11 is not at all barred the claim of the complainant.  As discussed earlier, the complainant proved his case by producing the exhibits stated above apart from his proof affidavit.  Ext.A2 dated 07.05.2016 is the discharge summary issued from Amrita Hospital in favour of the complainant’s mother Bhanumathi Amma.  If we peruse this document, it is revealed that in Amrita Hospital so many medical laboratory tests are conducted and also administered medicine for PW1’s mother.  It can be seen that the test conducted at Amrita Hospital was after the diagnise of liver cirrhosis.  Though any test is conducted it can be inferred that this is part of the treatment.  Ext.A3 dated 07.05.2016 is the bill in original issued from Amrita Hospital in favour of the complainant’s mother.  As per the bills, it is so clear to see that the PW1 paid Rs.16,364/- as the medical bill for his mother Bhanumathi Amma in Amrita  Institute of Medical Science & Research Centre, Kochi.  In the light of the evidence adduced by PW1, we can easily arrive a decision to the effect that the complainant is an insured of the opposite parties and his policy is still effective.  It is also find that the opposite parties are liable to pay the medical bill shown as Ext.A3 Rs.16,364/- as a medical reimbursement to the complainant.  The repudiation of the claim as per Ext.A4 is not sustainable on the basis of the above discussion.  In this case 1^st opposite party is the United India Insurance Company and the 2^nd opposite party is the Manager of the above said United India Insurance Company.  Therefore, opposite parties 1 and 2 are jointly and severally liable to the complainant.  Hence Point No.1 and 2 are found in favour of the complainant.

                   7. In the result, we pass the following orders:

1. The opposite parties are directed to pay the medical reimbursement Rs.16,364/- (Rupees Sixteen Thousand Three hundred and sixty four only)  with 10% interest from the date of filing of this petition, i.e. 30.05.2016.

2. The opposite parties are also directed to pay a compensation of Rs.7,500/- (Rupees Seven Thousand Five hundred only) and a cost of Rs.2,500/- (Rupees Two Thousand Five hundred only) to the complainant with 10% interest from the date order onwards.

         Dictated to the Confidential Assistant, transcribed and typed by her, corrected by me and pronounced in the Open Forum on this the 30^th day of November, 2016.

                                                                                    (Sd/-)

                                                     P. Satheesh Chandran Nair,

                                                                    (President)

Smt. K.P. Padmasree (Member – I)             :   (Sd/-)

Smt. Sheela Jacob (Member- II)                 :   (Sd/-)

Appendix:

Witness examined on the side of the complainant:

PW1  :  P. Sethunath

Exhibits marked on the side of the complainant:

A1 :  Copy of medical report for scanning dated 04.05.2015 issued by

        Muthoot Medical Centre, Pathanamthitta.

A2 :  Copy of discharge summary dated 07.05.2016 issued by Amrita Institute 

        of Medical Sciences & Research Centre, Kochi.

A3 :  Copy of bill dated 07.05.2016 for Rs.16,364/- issued by Amrita Institute

        of Medical Sciences & Research Centre, Kochi. 

A4 :  Copy of repudiation letter dated 07.05.2016 sent by opposite party to 

        Amrita Institute of Medical Sciences.    

Witness examined on the side of the opposite parties:  Nil.

Exhibits marked on the side of the opposite parties:  Nil.

                                                                                                          (By Order)

Copy to:- (1) P. Sethunath, Chempakathinal Puthenveedu, Prakkanam. P.O.,

                   Pathanamthitta – 689 643.

     (2) United India Insurance Co. Ltd., Family Health Plan (TDA) Ltd.,

          D. No.C.C.41/1064 C, Golden Plaza Annex Complex,

          2^nd Floor, Chittoor Road, Opp. Mymoon Theatre, Pullepadi Jn.,

          Ernakulam – 682 018.

     (3) Manager, United India Insurance Co. Ltd., 2^nd Floor,

          Kizhakkedathu Building, Central Jn., Pathanamthitta.         

     (4) The Stock File.                        .