<br /> <br /> By SRI.K. VIJAYAKUMARAN, PRESIDENT.<br /> <br /> This is a complaint for reimbursement of Medical expenses.<br /> <br /> The averments in the complaint can be briefly summarized as follows:<br /> <br /> <br /> The complainant’s case is that he is an employee of the opp.party 2 company. The employees of the company were memberof the Family Health Plan of the United India Insurance Company. As per the policy the family members of the insured are also covered. The complainant and his family members are also members of the above policy evidenced by Ext.P1. While so the 2nd opp.party handed over the insurance scheme to the 1st opp.party without any change of terms and conditions and without any brake from 31.12.2005 to 31.12.2006. The complainant has paid the premium without default. The complainant’s father fell ill and was admitted in the Holy Cross Hospital and undergone treatment from 1.1.200610.1.2006 for septicaemia COPO-BA and he had spend Rs.31500/- for his treatment. When he applied to opp.party 1 for the reimbursement of the expenses the claim was repudiated by opp.party 1 as per Ext.P3 on the ground that it is a pre existing disease, opp.party 1 has no right to repudiate the claim. Hence the complaint<br /> <br /> Opp.party 2 appeared and filed version. Opp.party 1 remained absent and hence was set exparte.<br /> <br /> Opp.party 2 filed a version stating that he is not a necessary party and that there is no deficiency in service on their part<br /> <br /> The point for consideration is whether there is deficiency in service on the part of the opp.parties ?<br /> <br /> PW.1 was examined and Ext. P1 to P5 were marked on the side of the complainant.<br /> <br /> <br /> <br /> Point<br /> <br /> <br /> There is no dispute that the complainant and his family are insured under Ext.P4 policy. The fact that the complainant’s father has undergone treatment at the Holy Cross Hospital is also not disputed. The grievance of the complainant is that his claim for reimbursement of medical expenses was repudiated as per Ext.P3 by opp.party 2 on the ground that it is a pre existing disease. Opp.party 1 remained absent and did not produce any material to establish that the disease for which the complainant’s father had undergone treatment was a pre existing one. The alleged doctors certificate is also not furnished. Ext.P3 clearly show that the policy is admitted. In the absence of any cogent material to establish that the complainant’s father was suffering from any pre existing disease. We hold that the repudiation is unsustainable and that there is deficiency in service on the part of the Opp.party. Point found accordingly.<br /> <br /> <br /> <br /> <br /> In the result the complaint allowed directing the opp.party 1 to reimbursement to the complainant Rs.31,500/- with interest @ 9% per annum from 12.6.2006 and to pay Rs.5000/- towards compensation and costs. The order is to be complied with within one month from the date of receipt of this order.<br /> <br /> <br /> <br /> <br /> Dated this the 29th day of July, 2008.<br /> <br /> <br /> <br /> I N D E X<br /> <br /> List of witnesses for the complainant<br /> PW.1. P. Anil Kumar<br /> <br /> <br /> List of documents for the complainant<br /> P1. – Family Health Cards issued by opp.party 1<br /> P2. – Certificate dated 5.1.2006<br /> P3. – Copy of letter dated 12.6.2006 to the opp.party 1 and 2<br /> P4. – Terms and conditions of Medical reimbursement<br /> P5. – Advocate notice dated 17.6.2006<br /> P5 [a] Postal receipt<br /> <br /> <br />