Sri. P. Satheesh Chandran Nair (President):

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

2. The case of the complainant is as follows:  the complainant has availed a policy by name and style health insurance policy - bearing registration No.395435185 from the opposite party with effect from 12/07/2011.  It is contented that the complainant had treated as an impatient from 28/09/2015 to 05/10/2015 and undergone for a SEPTOPLASTY surgery.  It is contented that the complainant had spent Rs.35,000/- for the said surgery and the opposite parties are liable to reimburse the said amount as per the said policy.  Though the complainant filed necessary application for the said reimbursement the opposite party paid only Rs.6,250/- and repudiated of other claim.  According to the complainant the act of the opposite parties are clear deficiency in service on their part and they are liable to the complainant.  Hence this case, for reimbursement of the medical expense compensation, cost etc. etc.
3. This forum entertained this complaint, and issued notice to the 1^st opposite party and the 2^nd opposite party for appearance.  The 1^st opposite party and the 2^nd opposite party entered appearance and filed a joint version as follows.  It is admitted that the opposite party has issued a Jeevan Arogya Plan (T 20) to the complainant and the said policy is not a medi-claim policy as claimed by the complainant.  It is contented that the alleged surgery undergone by the complainant was a plastic surgery on Nasal Septum for deviated Nasal Septum which is not at all a major surgery as per the above policy.  The complainant is only eligible for hospital cash benefit since the surgery was a day care procedure.   Therefore the opposite party paid Rs.6,250/- to the complainant on 03/12/2015.  It is contented that as per hospital card the complainant was admitted in surgical ICU for one day after the surgery.  It is also contended that the complainant filed a petition before the insurance ombudsman, Eranakulam for the above said grievances and the said petition was also dismissed on 29/09/2016.  According to the opposite parties they have not committed any deficiency in service or unfair trade practice against the complainant as alleged.  Therefore this opposite party prayed to dismiss the complaint with cost.
4. This Forum perused the complaint, version and records and framed 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?

5. 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.  Through PW1 Ext.A1 to A7 were also marked.  Ext.A1 is the medical certificate dated 04/04/2016.  Ext.A2 is the Hospital bill dated 05/10/2015 for an amount of Rs.33,922 (round up as 34,000/-).  Ext.A3 is the CT scan report dated 28/09/2015.  Ext.A4 is the Discharge summer dated 05/10/2015.  Ext.A5 is the policy certificate dated 12/07/2011.  Ext.A6 is the copy of letter issued by opposite party dated 07/12/2015.  Ext.A7 is the medical claim form dated 12/10/2015.  In order to substantiate the contention of the complainant PW1 he examined PW2 one Dr.Sheirly Varughese ENT Surgeon who issues Ext.A1 certificate to the complainant.  At the time of the cross examination of the PW1 Ext. B1 and B2 were also marked.  Ext.B1 is the decision of the insurance ombudsman award.  Ext.B2 is the copy of the insurance certificate.  After the closure of the evidence we heard both side.
6. Apart from the hearing of the opposite party’s counsel filed an argument note in favour of them. 
7. Point No.1: - The opposite party contented that the case is not maintainable either in law or on fact before this Forum.  When we peruse the evidence of this case it is clear that the complainant herein is an insured and the opposite parties are insurer of the complainant.  It is also proved that at the time of the hospitalization of the complainant the insurance policy was also in force.  Therefore we can find that the complainant is a consumer of the opposite parties and the opposite parties are service provider of the complainant.  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&3 together. The case of the complainant is that as the insured of the opposite party he is eligible to get a medical reimbursement as an insurance claim from the opposite parties.  In order to substantiate the contention of the complaint the complainant mainly relying on the medical certificate issued by the PW2 dated 04/04/2016 in favour of the complainant.  The said medical certificate is marked as Ext. A1.  Ext.A2 serious in 6 pages dated 05/10/2015 which shows that the complainant spent an amount of Rs.33,922/- for the surgery.  Ext.A3 dated 28/09/2015 which was issued from Thiruvalla medical mission shows that a surgery was done to the complainant for (1) Deviation of Nasal Septum to left side. (2) Hypertrophy of right inferior turbinate and (3) bilateral maxillary sinusitis.  The said certificate was issued by one Dr.Ram Kumar.S. MD. DNB consultant radiologist of said hospital.  It is also seen that this doctor referred the patient to one physician Dr.Sheirly Varghese.  Ext.A4 is a copy of names of different medicines prescribed at the time of discharge from Thiruvalla medical mission by Dr.Sheirly Varghese.  Ext.A5 is a copy of the LIC’s jeevan Arogya (Table 903) policy which was issued on 14^th September, 2011 In favour of the complainant.  Ext.A6 is a letter dated 07/12/2015 which was issued by the complainant to the 1^st opposite party asking for the reason for the non-payment of the eligible insurance claim.  Ext.A7 proved that the complainant filed a claim before the opposite party for the medical claim on 12/10/2015.  On the basis of the above contention and evidence we can see that there was a valid medical claim policies was prevailed at the time of the nasal surgery of the complainant as discussed earlier.  It is also admitted that the policy was in force at the time of surgery so that the opposite party paid an amount of Rs.6,250/-   by way of cheque to the complainant.  When we look into the version of the opposite party and other evidence adduced by them it is to see that the opposite party has a defenit stand to the effect that a day care surgery only done on the complainant so that he is not eligible to get the whole amount as reimbursement.  The opposite party’s learned counsel also argued that the decision of the insurance ombudsman award in Ext.B1 is binding to this Forum.   As per the provisions of Consumer Protection Act we are bound to look in to the deficiency in service of the opposite party in this regard.  Ext.B2 is the copy of the insurance certificate which was issued in favour of the complainant Ext.B2 page 1 and 2 and Ext.A5 page 1 and 2 are one and the same.  Along with Ext.B2 page 1 and 2 a brochure of LIC – jeevan Arogya - conditions and privileges (table 903) is also seen attached.  According to the learned counsel appearing for the complainant the said brochure was not given to the complainant at the inception of the said policy.  The opposite parties are also failed to produce any mutually signed paper with regard to the terms and condition of the said policy.
9. On the basis of the above discussion we can find that the case of the complainant is highly probable and the complainant succeeded to prove the deficiency in service against the 1^st opposite party and the 2^nd opposite party.  We are not in a position to see any kind of justification for not furnishing any reply in Ext.A2 notice by the 1^st opposite party for giving explanation for limiting the insurance claim for an amount of Rs.6,250/-.  On the basis of the above finding we would like to allow the medical reimbursement in favour of the complainant and also found that the non-payment of the medical reimbursement by the opposite parties are not justifiable and also liable to compensate the complainant.  The 2^nd opposite party is the branch manager of the 1^st opposite party.  Therefore the 1^st opposite party and 2^nd opposite party are jointly and severely liable to the complainant.
10. In the result we pass the following orders.

1. The 1^st and the 2^nd opposite party are hereby direct to reimburse the medical claim of Rs.27,750/- (Rupees Twenty Seven Thousand Seven Hundred and Fifty Only) (A2 Bill 34,000 - 6250) to the complainant with 10% interest from the date of receipt of this order onwards.
2. The 1^st & 2^nd opposite party are also directed to pay a compensation of Rs.5,000/- (Rupees Five Thousand Only) and the cost of  Rs.2,500/- (Rupees Two Thousand 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 27^th day of June, 2018.

                                                                                                                                                                       (Sd/-)

                                                                                                                     P.Satheesh Chandran Nair,

                                                                                                                                      (President)

• Smt. Sheela Jacob (Member):(Sd/-)

1. Witness examined on the side of the complainant:

PW1 :Moncy Thomas

PW2 :  Dr.Sheirly Varughese

Exhibits marked on the side of the complainant:

A1: Medical certificate dated 04/04/2016. 

A2: Hospital bill dated 05/10/2015. 

A3: CT scan report dated 28/09/2015.

A4: Discharge summer dated 05/10/2015.

A5: Policy certificate dated 12/07/2011. 

A6: Copy of letter issued by opposite party dated 07/12/2015.

A7: Medical claim form dated 12/10/2015.                       

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

Exhibits marked on the side of the opposite parties:

B1: Decision of the insurance ombudsman award.

B2: Copy of the insurance certificate.   

                                                                                                                                                                       (By Order)

          Copy to:-

1. Moncy Thomas,

S/o.Thomas, Valiyakadavil Veedu, Thengeli Muriyil P.O.,

Kuttoor Village, Thiruvalla Taluk.

2. The Divisional Manager,

Divisional Office, Jeevan Prakash, LIC of India, P.B.No.609,

3. The Branch Manager,

LIC of India, Marthoma Building, Thiruvalla.

4. The Stock file.