Sri. P. Satheesh Chandran Nair (President):

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

                   2. The case of the complainant is as follows:-  The complainant was availed a Health Insurance Policy with the 1^st opposite party bearing policy No.101700/48/14/00000136 and Card No.KOC-UI-S0816-000-0004707-A for him, wife and daughter for a sum of Rs. 3,00,000/-.  According to the complainant, the 2^nd opposite party has to reimburse the medical expenses incurred towards ailments/diseases happened to these persons.  It is contended that the complainant was admitted at Kerala Institute of Medical Sciences (KIMS), Thiruvananthapuram on 16/02/2015 for diminutive polyp sigmoid and rectum disease.  He was treated for two days in the said hospital and sent the details of the hospital treatment and expenses to 2^nd opposite party for getting the medical claim. The 2^nd opposite party repudiated his medical claim without stating any ground.  Subsequently to the discharge of the complainant from the hospital he submitted the detailed bill for an amount of Rs. 16,243/- to 2^nd opposite party.  Though the complainant again sent a letter on 18/09/2015 with regard to his claim the opposite party did not give any reply to both the claim or for the letter.  It is contended that the approach of the opposite party is clearly comes under the deficiency in service defined in Consumer Protection Act, 1986 and it is a clear violation of the terms and conditions of the said policy.  Hence this complaint, for the reimbursement of the above medical expenses of Rs. 16,243/-, interest and other relief ete.etc.

3. This Forum entertained the complaint and issued notice to opposite parties for their appearance.  The 1^st opposite party entered appearance and filed their version. Though the 2^nd opposite party received notice he did not appear before the Forum and on 20/05/2016 this Forum declared exparte against the 2^nd opposite party.   

4. The version of 1^st opposite party in brief is as follows: According to the 1^st opposite party, the complaint is not maintainable either in law or on facts.  It is admitted that the complainant availed a policy which is described in the complaint and the said policy was valid from 23/05/2014 to 22/05/2015.  It is contended that this policy covers the hospitalization and personal accident (death only) benefits to the policy holder and his family members as stated in the complaint.  It is further contended that the complainant herein submitted a claim on 09/03/2015 for the reimbursement of medical expenses of the complainant at KIMS Hospital, Thiruvananthapuram, which was repudiated by the 2^nd opposite party as the ailment for which the treatment was undergone was a pre-existing disease.  According to 1^st opposite party as per the terms and conditions described in No.4 and 4.1 ‘Any Pre-existing condition as defined in the policy, until 48 months of continuous coverage of such insured person have elapsed since inception of his/her first policy as mentioned in the schedule attached to the policy have been excluded’.   According to opposite party the cash less treatment can be availed according to the terms and conditions stipulated in the policy.   It is further contended that the complainant was suffering from a pre-existing disease that is why the opposite party repudiated the claim.  Therefore, this opposite party prayed to dismiss the complaint with their cost.

5. We peruse the complaint, version and records before us and framed the following issues for consideration:

1. Whether the complaint is maintainable before this Forum?
2. Whether the opposite parties committed any deficiency in service against the complainant?
3. Regarding the relief and costs?

6. In order to prove the case of the complainant, the complainant he who filed a proof affidavit in lieu of his chief examination and examined him as PW1.  Ext.A1 to A6 also were marked in favour of the complainant.  Ext.A1 is the Policy schedule and receipt issued by opposite party dated : 23/05/2014. Ext.A2 series are the photocopy of discharge summary and bills from KIMS Hospital, Thiruvananthapuram.  Ext.A3 is the copy of rejection letter issued by the 2^nd opposite party dated 16/02/2015. Ext.A4 is the copy of legal notice issued by the complainant to opposite parties dated 17/09/2015. Ext.A5 is the Postal receipt of Ext.A4 legal notice dated 17/09/2015. Ext. A6 is the postal receipt dated 09.03.2015.  In this case opposite parties did not adduce any oral evidence in their favour but the learned counsel appearing for the opposite party cross-examined PW1. No documents were marked on their favour.  After the closure of evidence, we heard both sides. 

7. Point No.1:  The case of the 1^st opposite party is that the case is not maintainable either in law or on facts. It is pertinent to see that the opposite party in this case admitted that the complainant and his family members stated in the complaints are availed a medical reimbursement policy from the opposite parties.  The said policy was valid at the time of the treatment of complainant at KIMS Hospital. Therefore, it can be easily inferred that the complainant is a consumer of the opposite party, and the opposite parties are service providers.  Hence Point No.1 found in favour of the complainant.

8. Point No.2 & 3:- For the sake of convenience, we would like to consider Point No.2 and 3 together.  When we evaluate the whole evidence of the case it is to see that the main question to be considered is whether the opposite parties committed any deficiency in service against the complainant.  In order to prove the case of the complainant, the complainant is mainly relying Ext. A1 policy certificate and Ext.A2 series medical bill.  The medical expenditure incurred to the complainant is specifically mentioned in Ext.A2 series.  The repudiation letter which is marked as Ext.A3 shows that the medical claim was repudiated by the opposite party as – ‘fresh policy - possible pre-existing ailment and cash less not possible’.  The Ext.A4 legal notice to opposite parties shows that he claimed a reimbursement of Rs.16,243/- from the opposite parties for his medical expenses.   Though the learned counsel appearing for the opposite party 1 cross-examined PW1 with regard to pre-existing disease, nothing brought out to see that the complainant suffered a pre-existing disease known as ‘diminutive polyp sigmoid and rectum’ at the time of availing the policy.  In cross he answered,  “Kims Hospital-  t]mIpw ap³]v Cu Akp-J-¯n\v treatment FSp-¯n-Ô.  In the light of the evidence adduced by the complainant it is to see that the complaint has not suffering any pre-existing disease known as of ‘diminutive polyp sigmoid and rectum’ at the inception of the policy.  The next point to be considered is whether the repudiation of Ext.A3 letter is justifiable or not.  In that letter the reason for the rejection of the claim is due to pre-existing ailment.  But as stated earlier that has not been proved by the opposite parties in this case.  It is true that the opposite party has pleaded that the complainant failed to produce proper medical bill along with the claim before the opposite parties.  In cross-examination PW1 answered, “2015 March  amkw Rm³ bill submit  sNbvXp. bill klnXw  claim submit sNbvX tijw claim reject sNbvtXm F¶ hnhcw F\n¡v e`n-¨n-«n-Ã. Ext. A3 letter cashless claim \v th­n sImSp¯ claim Bbn-cp-¶p.  Subsequent claim reject sNbvX hnh-c-¯n\v \mfn-Xp-hsc reply In«nbn«nÔ.   In the light of the above testimony of PW1 it is clear that a claim of PW1 is still pending before the opposite parties.  It is also proves that the first claim form submitted by PW1 was a cash less claim.  Therefore, it can be inferred that the repudiation of Ext.A3 claim is justifiable because that claim is a cash less claim.  Apart from that it is seen that the finding of the opposite party with regard to pre-existing disease, which is shown in Ext.A3 is not justifiable.

9. When we peruse the version and deposition of PW1, it reveals that opposite parties did not raise any serious contention with regard to medical expenses incurred by PW1.  Ext.A6 is the letter issued by the complainant against opposite party 1 on 09/03/2015.  In that letter the complainant PW1 requested the opposite party to condone the delay for the submission of detailed bill.  In the light of the above said answer, it can be inferred that the medical claim of the complainant is still pending before 1^st opposite party and it is still under process.  The complainant proved that so far the opposite party has not given any explanation with regard to the pending medical claim which was filed by the complainant/PW1.  Therefore, we find that the 1^st opposite party has committed deficiency in service with regard to the process of complainant’s medical claim. As stated earlier, 2^nd opposite party was set exparte on 20/05/2016 as such the evidence adduced by the complainant against 2^nd opposite party is unchallengeable.  It is also find that the opposite party 1 & 2 are equally and severely liable to the complainant.  Apart from that it is also find that there is no pre-existing disease with regard to the subject matter of the medical claim submitted by the complainant to the opposite parties.  Hence the complaint is allowable, therefore Point No.2 and 3 also found in favour of the complainant.

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

1. The Opposite parties 1 & 2 are directed to realize Rs.16,243/-(Rupees Sixteen Thousand two hundred and forty three only) as medical reimbursement of complainant health insurance scheme with 10% interest from the date of filing of this petition i.e., 12/04/2016 onwards.
2. The Opposite parties are also directed to pay a compensation of Rs. 5,000/- (Rupees Five Thousand only) and a cost of Rs. 2,500/- (Rupees Two Thousand and Five hundred only) to the complainant with 10% interest from the date of receipt of this 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 January, 2016.

                                                                                              (Sd/-)

                                                                   P. Satheesh Chandran Nair,                                                                                                                                                                                                                                              

                                                                                         (President)

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

Appendix:

Witness examined on the side of the complainant:

PW1  : Blesson Sam

Exhibits marked on the side of the complainant:

A1 : Policy schedule and receipt issued by opposite party dated 23/05/2014.

A2 series :  Photocopy of discharge summary and bills from KIMS Hospital, 

                  Thiruvananthapuram.

A3 :  Copy of rejection letter issued by the 2^nd opposite party dated 16/02/2015.

A4 :  Copy of legal notice issued by the complainant to opposite parties dated 17/09/2015.

A5 :  Postal receipt of Ext.A4 legal notice dated 17/09/2015.

A6 :  Postal receipt dated 09.03.2015.

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. Blesson Sam, Vilayil Vadakkethil, Chayalode P.O,

                    Nedumon Muri, Ezhamkulam Village, Adoor Taluk,

                    Pathanamthitta District – 691 556.

            2. The Divisional Manager,

           United India Insurance Co. Ltd., Kizhakkedathu Building,

           P.B.No.34, Main Road, Pathanamthitta – 689 645.

3. The Authorized Officer,Vidal Health TPA Pvt. Ltd.,

            No. 39-4130, 1^st Floor, Mareena Building, M.G.Road,

                     Ravipuram, Ernakulam, Cochin – 682 016.

4. The Stock File.