This is a complaint filed under section 12 of consumer protection Act for an order directing the opposite party to pay `31,300 to complainant as hospital expenses and compensation.

          The case of the complainant in brief is as follows: Complainant is a holder of universal Health Insurance Policy under the opposite party for the last 5 years. As per the policy there is coverage of `30,000. He has approached ENT Specialist Dr.Arun Divakaran, in Koyili Hospital, Kannur on 13.4.12 due to the problem of variation of his sound. After examination it was diagnosed as (L) Vocal Cord cyst and advised to send for Biopsy. It was also told that it is only a minor operation less serious than that of Tonsillectomy and can be discharged on the same day. Thus he was admitted at 7 A.M on 21.4.12 for operation. He was given anesthesia at 9 A.M and conducted operation. He was then discharged at 5 P.M. He paid 6300 as expense. Claim was preferred with all the documents but it was returned on the ground that it lacks I.P Number. Complainant again approached Doctor to get the I.P. Number but doctor told him that no IP number since it was a theatre discharge. Doctor told him that since the patient was discharged from operation theatre there shall be only operation number. Hence operation number was filled in the I.P column and the same was received by opposite party on 18.05.12. But it was repudiated and intimation letter received on 11.7.2012 on the ground of admission less than 24 hrs. Even as per the conditions of policy, hospitalization is required only less than 24 hours in many cases. Hence repudiation of claim is a deficiency in service.

 Opposite party filed version after appearance contending that the complainant was not an inpatient as specified in terms and conditions and other clauses contained in the policy. So the claim of the complaint cannot be accepted.

          On the above pleadings the following issues have been taken for consideration.

1.     Whether there is any deficiency in service on the part of

               opposite   party?

2.     Whether the complainant is entitled to get the relief as

       prayed in   the complaint?

3. Relief and cost.

The evidence consists of the oral testimony of PW1 and Exts.A1 toA10.

Issue Nos.1 to 3

                    Admittedly complainant is policy holder namely Universal Health Insurance Policy under opposite party. The sum assured `30,000 has also been admitted by opposite party. Complainant’s case is that he was hospitalized  on  21.04.12 at 7 A.M in Koyili Hospital, Kannur for conducting MLS under General Anesthesia and discharged him at 5 P.M. The insurance claim was rejected by opposite party on the ground that the treatment was taken by the complainant not as an inpatient.

          Complainant adduced evidence by means of chief affidavit in tune with his pleadings. He has stated that on 21.4.2012 he was admitted in Koyili Hospital at 7 A.M and MLS was done under General Anesthesia. Ext.A6 makes it ascertain that the complainant was admitted in Koyili Hospital on 21.04.12 under consultant Dr.Arun Divakar. Discharge summary quite clearly recorded in diagnosis as (L) Vocal Cord Cyst. Treatment recorded as follows: “MLS done under G.A – 21.04.12(Specimen sent for HPE”. Medicines also prescribed.

          Opposite party did not say any thing about the treatment of the complainant.PW1 in his cross examination deposed thus: 21.04.12 \p H³]Xp aWn¡v Fs¶ Hm¸tdj³ sNbvXncp¶p”. Ext.A7 description   goes to show that the case of the complainant was  OP discharge.

          The evidence on record undoubtedly goes to show that the complainant was admitted in the hospital on 21.4.12 and undergone MLS under general Anesthesia for the purpose of sending specimen for HPE. Why does it was not considered as an admission is  a question supposed to be explained by opposite party in the light of clause  2.3 of the policy which states as follows:

“Expenses on Hospitalization for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments, i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy /(Kidney stone removal),D&C, Tonsillectomy taken in the Hospital/Nursing Home and the insured is discharged     on the same day, such treatment will be considered to be taken under hospitalization Benefit. This condition will also not apply in case of stay in Hospital of less than 24 hours provided”

a)     The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in hospitals.

b)     Due to technological advances hospitalization is required for less than 24 hours only.

Note: When treatment such as dialysis, chemotherapy,

        Radiotherapy, etc. is taken in the hospital/nursing home and

         the insured is discharged on the same day the treatment will

         be considered to be taken under hospitalization benefit

         section.

Liability of the company under this clause is restricted as stated in the Schedule attached hereto.

          What is the meaning of sub clause (b) of clause 2.3.Even a man of ordinary prudence can under stand that the insurance company has accepted the scientific technological development of present world by declaring themselves that “ Due to technological  advances hospitalization is required for less than 24 hours only”. Opposite party has no case the disease diagnosed is one that is in the exclusion clause. MLS is done for the purpose of sending specimen for HPE. If this expense is not considered especially when hospitalization is required only less than 24 hours due to technological advances, what also can be expected to be considered under this benefit. So there is no doubt the repudiation of claim by the opposite party is a gross negligence on the part of opposite party. They have not closely gone through their own terms and conditions applying mind intaking decision upon the claim of complainant. The claim of the complainant is a genuine claim. The repudiation of claim could not save the interest of the company but spoils the best name of the company creating bad impression in the mind of the public regarding its sincerity. It only reveals the symptoms of unfair trade practice. We have no hesitation to say that opposite party is liable to pay the claim amount `6300 since the repudiation is a deficiency in service on the part of opposite party. Opposite party is also liable to pay compensation to the tune of `3000 and cost of these proceedings a sum of `1000. Thus issues 1 to 3 are found in favour of complainant and order passed accordingly.

          In the result, the complaint is allowed directing the opposite party to pay `6,300 (Rupees Six thousand and Three hundred only) as  claim amount together with   `3,000 (Rupees Three thousand only) as compensation and  `1000 (Rupees One Thousand only) as cost of this proceedings to the complainant within one month from the date of receipt of this order, failing which the complainant is at liberty to execute the order after the expiry of one month as per the provisions of consumer protection Act. 

                     Sd/-                  Sd/-                 Sd/-                     

President              Member                Member

                           APPENDIX

Exhibits for the complainant

A1. Prescription

 A2. Pathological lab report

 A3. ECG

A4.  Medical certificate

A5.  Medicine bill

A6.  Biopsy Result

A7.  Hospital bill

A8.  Discharge summary

A9. Repudiation letter sent by OP

A10. Copy of the insurance policy

Exhibits for the opposite parties:

 Nil

Witness examined for the complainant

PW1.Complainant

Witness examined for the opposite parties:

 Nil

                    /forwarded by order/

          Senior Superintendent

Consumer Dispute  Redressal Forum, Kannur.