IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Thursday the 30th day of July, 2009
Filed on 09.05.2007
Present
- Sri. Jimmy Korah (President)
- Sri. K. Anirudhan (Member)
- Smt. Shajitha Beevi (Member)
in
C.C.No.98/2007
between
Complainant:- Opposite Party:-
Sri. N.T. Ramadas United India Insurance Co.
High School Assistant Ltd., Cherthala Branch, NSS
Nilamnikarthil House Union Building, Cherthala
Thaickal P.O., Cherthala-688 538 Pin – 688 524, Represented
(By Adv. P.V. Thomas) by its Branch Manager
(By Adv. C. Muraleedharan
O R D E R
JIMMI KORAH (PRESIDENT)
The case of the complainant is that he is mediclaim policy holder of the opposite party. His mother Saraswathy was also covered under this policy. He made a claim along with relevant documents for the reimbursement of the treatment of his mother. The claimed amount is Rs.7677/-. The opposite party repudiated the claim. Hence he preferred this complaint before this forum.
2. Opposite party filed version stating that complainant’s mother underwent treatment for heart disease. She is a diabetic patient since 2002. This fact was not disclosed at the time of taking the policy. Hence they prayed for the dismissal of the petition.
3. Complainant examined and filed 4 documents which are marked as Exts. A1 to A4. Opposite party examined one witness and produced 5 documents which are marked Exts. B1to B2.
4. Considering the rival contentions of both parties this Forum framed following issues:-
Whether there is any deficiency of service on the part of the opposite party by repudiating the claim?
5. There is no dispute with regard to the policy and amount of treatment. Only dispute is with regard to the fact about preexisting disease or not. Exhibit A1 is the terms and conditions of the policy. The policy covers “… a disease or suffer from any illness…”. Clause 3.0 ANY ONE ILLNESS defines as follows “Any one illness will be deemed to mean continuous period of illness and it includes relapse within 105 days from the date of discharge from the hospital/nursing home where treatment has been taken. Occurrence of the same illness after a lapse of 105 days as stated above will be considered as fresh illness for the purpose of this policy”. The opposite party has no case that policy was taken within 105 days back to the date of admission in the hospital and she had the disease within that 105 days. The policy starts from 8-3-2005 to 7-3-2006. The policy is continues policy. Further diabetic mellitus is not a disease or illness, it may be one of the reasons for the cause of heart disease. The wordings in the policy are clear and there is no ambiguity. Hence the repudiation of the claim of the complaint is false and not sustainable. Hence we directed the opposite party to pay Rs.7677/- with 9% interest from the date of filing of this complaint (9-5-2007) till realization. The complainant is also entitled to get Rs.2000/- cost of the proceedings .
Complaint allowed.
Pronounced in open Forum on this the 30th day of July, 2009.
Sd/- Sri. Jimmy Korah:
Sd/- Sri. K. Anirudhan:
Sd/- Smt.N.Shajitha Beevi
Appendix:-
Evidence of the complainant:-
PW1 - N.T.Ramadas (Witness)
Ext.A1 - Policy schedule – Universal Health Insurance
Ext.A2 - Policy schedule – Medi Guard Policy
Ext.A3 - Medi-Guard policy terms and conditions
Ext.A4 - Regd. Letter with a/d dated 21.4.2006
Evidence of the opposite party:-
RW1 - Ambily Vasudevan E. (Witness)
Ext.B1 - Copy of the medi guard policy (office copy)
Ext.B2 - Copy of the claim form
Ext.B3 - Copy of the policy renewed
Ext.B4 - Copy of the Reg. letter with a/d dt. 21.4.2006
// True Copy //
By Order
Senior Superintendent
To
Complainants/Opposite party/S.F.
Typed by :-pr/-
Compared by:-
