By Smt. Padmini sudheesh, President The case of the petitioner is that the respondent company has issued a Janaseva Insurance Policy (Type F) N.570704/42/2001/8204587 for the period 27/2/02 to 26/2/05 to the petitioner. As per the policy complainant is entitled for treatment expenses up to Rs.5000/-. On January 2003 complainant had consulted Dr.Subha Rao in St.Joseph Hospital, Poovathussery for anemia and the doctor suggested for better treatment and conducted scanning and some other tests in Little Flower Hospital, Angamali. As per the direction of the doctor, medicines had taken for a long period. Later the complainant applied to the company for insurance benefits. But it was rejected on 17/4/03 stating a new reason not stated earlier. On 15/7/04 again she had consulted doctor and on 19/7/04 she had undergone an operation for removing Fibroid from uterus. She had incurred Rs.15,000/- towards the hospital expenses. On 28/9/04 she had again approached the company for insurance benefits. It was also rejected stating preexisting diseases are exempted from the purview of policy. Hence this complaint. 2. The counter in brief is as follows: As per the policy issued to Janaseva Foundation, If the insured person shall sustain any bodily injury solely and directly from accident caused by external violent and visible means, resulting in death/disablement as stated, then company shall pay to the insured person or his legal personal representatives the sum insured as set forth in the policy schedule. Further as per group medi-claim, a maximum of Rs.5000/- towards hospitalization medical expenses as per the standard medi-claim policy of the company are admissible. As per Medi-claim Insurance policy exclusions, the company is not liable to make any payment under this policy incurred by any insured person in connection with or in respect of (i) all diseases/injuries which are pre-existing when the cover incepts for the first time (ii) any diseases contracted by the insured person during first 30 days from the commencement period of insurance cover (iii) some specifically mentioned diseases during the first year of the operation of the policy among others. Any pre-existing disease or complication arising from pre-existing disease/injury are excluded from the provisions of the policy. This respondent denies all the averments in para 7 of the complaint with regard to hospitalization in 2004. The averment that the doctors at Lourde Hospital, Ernakulam has diagnosed that the complainant is suffering from FYBROID UTERUS is not correct. Even the Ultra Sound scan of complete abdomen of the complainant taken on 7/1/03 clearly shows that complainant was suffering from Fibroid. The complainant has suppressed the above facts in her second claim application submitted before the respondent. Moreover the medical report issued by Dr.Sherly Mathew, Lourdes Hospital, Kochi clearly stated complainant was suffering from the disease for the last one year. The averment that the complainant came to know about fibroid uterus only on 15/7/04 is not correct. She is not entitled for any relief. Hence dismissed. 3. The points for consideration are : 1) Is there any deficiency in service ? 2) Is the complainant is entitled to get policy benefits ? 3) Reliefs and costs ? 4. The evidence consists of Exhibits P1 to P3 and R1 to R10. 5. Point No.1 : The policy period was from 27/2/02 to 26/2/05 It is evidenced by Exhibit P1 and admitted by the respondent also. On January 2003 the complainant had consulted doctor for the first time. That was within the period of the policy. The reason for rejection is not genuine, because it was an added condition. It was not applicable during the inception of policy. There is nothing to show that before joining the policy that condition was prevailed. On 19/7/04 the complainant had undergone an operation for removal of fibroid. On 15/7/04 she had admitted. That was also within the policy coverage. Hence prima facie itself the complainant is entitled for the policy amount. In the version it is stated that the ultra sound scan of abdomen taken on 7/1/03 shows that the complainant was suffering from fibroid. Even if she was suffering from the disease for a long time, there is nothing to show that she had taken treatment for the disease before joining the policy. So the petitioner is entitled to get the policy benefits. The limit of the policy amount is Rs.5000/-. Hence the complainant is entitled to get that amount only. 6.Point No.2 : There is deficiency in service on the part of respondent company. Repudiation of a genuine claim is a deficiency in service. 7. In the result the complaint is allowed and the respondent company is directed to provide Rs.5000/-(Rupees Five thousand only) with 12% interest from 15/7/04 and 6% till realization. Complainant is also entitled for Rs.1000/- (Rupees One thousand only) towards costs. Comply the order within two months. Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open Forum this the 11th day of August 2008.
