By Smt.Rajani.P.S., Member
The complainant’s case is as follows: The complainant and his family have taken a mediguard insurance policy for Rs.25,000/- each (total Rupee one lakh) under Policy No.100606/48/06/12/00005243 dated 12/1/07 from the respondent. He paid Rs.1358/- towards the premium on the same day. The respondent promised to give the treatment expenses occurred during the policy period. The complainant had taken an insurance policy under Janarogya Insurance policy from 2001 onwards. On 1/1/2006 the complainant undergone a surgery due to swelling on the left leg at St.James Hospital and the complainant availed Rs.5,000/- as treatment expenses under Janarogya Insurance policy. At the time of joining the 2nd policy the respondent never stated that he will not be given insurance coverage if this disease comes again. On 19/2/07 he was admitted to St.James Hospital, Chalakkudy for conducting a surgery for ‘Perianal abcess’ on the right leg and he was discharged on 27/2/2007. He spent Rs.6468/- for his treatment. He submitted a claim with all requisite documents. But the said claim was repudiated by stating pre-existing disease. There is no basis for repudiating the claim. The present disease is not a continuation of the disease for which the claim was allowed as per Janarogya policy. The repudiation of the claim amounts to deficiency in service and an unfair trade practice. Hence the complaint.
2. Counter filed by the respondent is that the policy No. 100606/48/06/12/00005243 is a Mediguard policy issued in favour of the complainant and his family members. The said policy is operative only subject to the terms and conditions stipulated there in. As per the Janarogya policy, the complainant availed the expenses of treatment for Perianal abcess. He was first consulted for the treatment of the same on 28/12/06 with Dr.C.Thilakan of PAT hospital, Mambra with OP No.A.64997. He was then referred to perianal abcess on 1/1/07 which can seen from the medical certificate dated 11/1/07. issued by Dr.Kurian Thomas of St.James Hospital, Chalakkudy. The 1st operation date stated in the complaint is not correct. This treatment expenses were availed by the complainant by his earlier claim. After discharging from the hospital on 11/1/07 he took the medi guard policy on 12/1/07. For the same disease he was then admitted on 19/2/07 in St.James Hospital, Chalakkudy and underwent another operation for Perianal abcess on 20/2/07 and was discharged on 27/2/07. The complainant has claimed the expenses related to the same disease Perianal Abcess which has recurred for which he had preferred the claim earlier. Hence this disease Perianal abcess which is a preexisting one is a bar for entertaining a mediguard policy claim. Therefore the 2nd policy is inoperative due to the above reasons and the complainant is not entitled for getting any amount of compensation or expenses for treatment. Whatever allegations in the complaint contrary to the statement above, with respect to the disease, policy and alleged claims are false and hence they are denied. Pre-existing diseases are outside the scope of this mediguard policy that can be seen from the relevant documents. This respondent has timely informed the complainant with respect to the repudiation of claim with reasons. Hence dismiss.
3. Points for consideration are :
1) Is there any deficiency in service on the part of respondent?
2) If so cost and compensation?
4. The evidence consists of Exhibits P1 to P6 and Exhibits R1 to R7. No oral evidence adduced by both.
5. The case of the complainant is that he and his family members had taken a Mediguard policy for Rs.25,000/- each from the respondent on 12/1/07. The complainant had taken another policy in the name Janarogya insurance from the same respondent since 2001. On 1/1/2006 he had undergone a surgery for inflammation on the left leg and he received Rs.5000/- as per this policy. On 19/2/2007 he was admitted in the hospital and undergone surgery for inflammation on the right leg. When the claim was submitted under the Mediguard policy, the respondent repudiated the claim stating that the treatment was for pre-existing disease.
6. The respondent in their counter states that the policy coverage is subject to the policy terms and conditions. As per the Janarogya policy the complainant availed the treatment expenses for perianal abcess. He was first consulted for the treatment of the same on 28/12/2006 and the operation was done. This treatment expenses were availed by him as per the said policy. On 19/2/2007 for the same disease he was admitted in hospital land underwent surgery. The complainant has claimed the expenses related to the same disease which has recurred for which he had preferred the claim earlier. Hence this disease Perianal Abcess which is a pre-existing one is a bar for entertaining a Mediguard policy claim.
7. Exhibit R4 would show that the complainant was treated for Perianal Abcess from 31/12/06 to 11/1/07 which was well before the commencement of the Mediguard policy. The respondent admitted in their counter that the complainant had treated for the said disease earlier which was well within the policy period under Janarogya Insurance policy. The respondent joined a separate policy immediately after the 1st claim was produced i.e. on 12/1/07 So the respondent shall not entertain another policy in the name of this person again or they should convince the complainant that they will not prefer a claim for the same disease again. If the complainant was made to convince these policy conditions surely they will not join a separate policy. Hence the complainant was cunningly trapped by the respondent by issuing another policy immediately after a claim was put forward. The act of the respondent amounts to unfair trade practice and deficiency in service. As far as the new policy is concerned this is a fresh claim and he is entitled to get the claimed treatment expenses.
8. In the result the complaint is allowed and the respondent is directed to pay the treatment expenses as prayed with compensation of Rs.1,000/- (Rupees One thousand only) and costs Rs.500/- within one month from the date of receipt of copy of this order. Otherwise the claimed amount will carry 12% interest from the date of claim.
Dictated to the Confdl. Asst., transcriber by her, corrected by me and pronounced in the open Forum this the 28th day of October 2010.
