This Complaint coming up before us for hearing on 13-04-11 in the presence of Sri G.J.R. Kumar, advocate for complainant and of              Sri Ch. Y. Narayana, advocate for opposite party,                              upon perusing the material on record and after hearing both sides and having stood over till this day for consideration this Forum made the following:-

O R D E R

Per Sri A. Hazarath Rao, President:-

        The complainant filed this complaint U/S 12 of Consumer Protection Act, 1986 seeking a sum of Rs.37,261/- being the amount spent towards medical bills, Rs.10,000/- towards mental agony and Rs.5,000/- towards costs.

2. In brief the averments of the complaint are these:

        The complainant along with her husband and son obtained            Medi-claim policy bearing No.052100/48/06/21/00000350 from the opposite party.   The policy period was from 30-09-06 to 29-09-07 and the sum insured was Rs.50,000/-.  The complainant and her son Collins were hospitalized in M/s Lakshmi Nursing Home for viral fever and pneumonia respectively.   The complainant lodged the claim on 15-05-07 for a sum of Rs.37,261/- along with relevant papers.   As per the terms and conditions of the policy the insured has to be treated by a qualified medical practitioner having a hospital or nursing home within the local authorities.   The claimant through her husband appeared before the ombudsman who dismissed the claim of the complainant. The opposite party wrongly took the view that the concerned Dr. Y. Bhaskar Rao is only having two beds and they will work for 24 hours and consultations on phone and there is inpatient register being maintained by him.  The complaint therefore be allowed.

3. The contention of the opposite party in brief     is hereunder:    

The complainant is not a direct consumer of the opposite party.  The complainant was a consumer of M/s Unique Mercantile India Private Limited.   As per salient features of the Insurance policy the insured must inform about the hospitalization immediately to Unique Mercantile India Private Limited and TPA for necessary assistance.   The complaint is bad for non joinder of necessary party i.e., M/s Unique Mercantile India Private Limited.   As per the Medi-claim certificate the policy holders are K. Anthony Wilson, K.W.Selvy and K.N.Kolins.  As per claim intimation letter the patient was shown as                    K. Anthony Wilson.   As per the documents filed by the complainant the patients are K.W. Selvy and K.N.Kolins.   Husband of the complainant on 17-05-07 intimated the opposite party about hospitalization.   After personal enquiry the opposite party repudiated the claim on 26-11-07.    The opposite party did not commit deficiency of service.  The complaint is barred by limitation.  The hospital with which the complainant took treatment was at a distance of 3 kilometers.   There were number of super specialty hospitals in old club road, Guntur.  The complainant intentionally suppressed the material facts.  The complaint therefore be dismissed.

4.      Exs.A-1 to A-12 on behalf of the complainant and Exs.B-1 to B-7 on behalf of opposite party were marked.

5.   Now the points that arose for consideration in this complaint are:

1.Whether the complaint is barred by limitation?

2.Whether the opposite party committed deficiency of service?

3.Whether the complainant is entitled to compensation?

4.To what relief?

6.     POINT No.1:-   The opposite party repudiated claim of the opposite party on 26-11-07 as seen from Ex.A-11(=B-6).  The complaint was filed on 23-11-09 vide SR.No.2705.  Hence, the complaint is in time as required under Sec.24 (a) of Consumer Protection Act. Therefore, this point is answered in favour of complainant.

7.   POINTS 2 & 3:-   The opposite party repudiated the claim as detailed infra:

                “We refer you to our letter dated 04-10-07 where in we have requested you to submit the discharge summary and printed numbered receipt of the hospital, till today we have not received the same.

                Further we have investigated the claim and Dr. Y. Bhaskar        Rao of M/s Lakshmi Nursing Home confirmed that hospital is not       maintaining any medical records and only two beds are available    in the hospital.  The said hospital does not fall under the    definition of hospital and the claim is not admissible under Group     Mediclaim policy.

                Under the above circumstances we are treating the claim         as no claim.  Which please note”.

8.     The said repudiation is being questioned by the complainant by filing a complaint before the Consumer Forum.   The terms and conditions of policy will govern the insurer and insured.   The complainant taking Medi-claim policy for herself and her husband and son is not in dispute.   Ex.A-1(=B-1) is the copy of Medi-claim policy along with terms and conditions.   Clause 2 of Ex.A-1 deals with definitions.  Clause 2 (1) of Ex.A-1 defines hospital/nursing home and it reads as follows:

          “The terms Hospital/nursing home means any institution in India established for indoor care and treatment of sickness and injuries and which either a) has been registered as a Hospital or Nursing home with the local authorities and is under the supervision of a registered and qualified medical practitioner or b) should comply with minimum criteria as under:- I) it should have at least 15 inpatient beds. ii) fully equipped operation theatre of its own wherever surgical operations are carried out iii) fully qualified nursing staff under its employment round the clock. IV) fully qualified doctor(s) should be in-charge round the clock”.

9.     It is for the complainant to satisfy those requirements by cogent evidence to claim amount under Medi-claim policy particularly when the insurer is denying existence of those conditions in M/s Lakshmi Nursing Home.   The complainant did not file even the affidavit of               Dr. Y. Bhaskara Rao regarding the availability of such conditions in his nursing home.   Even the complaint as well as her affidavit was silent whether the said hospital satisfied those conditions or not.   In the absence of those particulars the repudiation of claim by the opposite party is justified and it did not commit any deficiency of service.   As the opposite party did not commit any deficiency of service, the complainant is not entitled to claim any compensation.  Hence, these points are answered in favour of the opposite party. 

10.   POINT No.3:-   In view of the findings on point No.2, in the result, the complaint is dismissed without costs.

Dictated to Junior Steno, transcribed by her, corrected by me and pronounced in the open Forum dated this the 25th day of April, 2011.

Sd/-XXX                                           Sd/-XXX                             Sd/-XXX

MEMBER                                                         MEMBER                                 PRESIDENT

APPENDIX OF EVIDENCE

    DOCUMENTS MARKED

For Complainant:

For opposite party:        

                                                                                                                 PRESIDENT