ORDER<br /> <br /> Sri. Jacob Stephen (President):<br /> <br /> The complainant has filed this complaint against the opposite parties for getting a relief from the Forum.<br /> <br /> 2. The brief facts of the complainant’s case is as follows: The complainant is a medi-claim policy-holder of the opposite parties vide policy No.100506/48/37/4487/01 valid from 06.06.2001 to 05.06.2002. While so, the complainant has undergone treatment at Poyyanil Hospital, Kozhencherry from 3.12.2001 to 08.12.2001 as inpatient for headache/eltimoid sinusitis and sphenoid sinusitis. She had spent an amount of Rs.7,495-38 for the treatment. Since she had a valid medi-claim policy, her husband had made a claim before the opposite parties for the realisation of the medical expenses incurred by her. But the opposite parties have refused the claim stating that the disease for which the complainant procured treatment is a pre-existing disease, which does not cover the policy. The opposite parties have also alleged that the complainant was treated for the same disease as an outpatient on 15.05.2000 to 20.5.2000 and 16.03.1999 at Poyyanil Hospital. The above said repudiation is a deficiency of service from the part of the opposite parties, which caused mental agony, distress and financial crisis to the complainant. So the complainant is entitled to get the medical expenses, compensation for the damages etc. for Rs.5,000/- and cost of Rs.1,000/- with interest. Hence this complaint is filed for getting an order against the opposite parties for the realisation of the aforesaid amounts.<br /> <br /> 3. For the opposite parties, the first opposite party filed a common version contending the following: The complaint is not maintainable either in law or on facts. They are admitting the validity of the policy. On getting the claim letter from the complainant’s husband, the opposite parties referred the matter for investigation to Sri. V.V. George who investigated and filed his report on 21.02.2002.. The investigator reported that the complainant had suffering from headache for a long time prior to her hospitalisation. She has already on treatment for the history of headache as an outpatient from 15.5.2000, 20.5.2000 and on 16.3.1999 at Poyyanil Hospital, Kozhencherry. Since the complainant was already on treatment from 16.03.1999, the complainant’s disease was pre-existing before the commencement of the policy. Since the complainant’s disease is a pre-existing disease, which does not cover the medi-claim policy. They are perfectly right in repudiating the complainant’s claim. Thus, there is no deficiency of service from their part and the complainant is not entitled to get any reliefs prayed for in the complaint. So the opposite parties canvassed for the dismissal of the complaint with their cost.<br /> <br /> 4. On the above pleadings, the following points are raised for consideration:<br /> (1)Whether the complaint is maintainable before this Forum?<br /> (2)Whether the complainant is entitled to get a relief as prayed for in the<br /> complaint?<br /> (3)Reliefs and Costs?<br /> <br /> 5. The evidence in this case consists of the oral evidence of the complainant who has been examined as PW1 and the documents produced by her were marked as Exts.A1 to A3 on the basis of the proof affidavit filed by the complainant and Ext.A4 marked through DW1. For the opposite parties, the third opposite party has been examined as DW1 and Exts.B1, B2 series and Ext.B3 were marked through PW1. After closure of the evidence, both sides heard.<br /> <br /> 6. Point No.1: The complainant herein availed the services of the opposite parties by taking a medi-claim policy. So the complainant is a consumer of the opposite parties and the dispute in between the parties is a consumer dispute and hence point No.1 answered in favour of the complainant.<br /> <br /> 7 Points 2 & 3: In order to prove the complainant’s cases, he deposed before this Forum that she had availed medi-claim policy from the opposite parties vide Ext.A1 policy No.100506/48/37/4487/01 valid from 6.6.2001 to 5.6.2002. The said policy was taken by her husband for himself and to his family including PW1. During the validity of the said policy, she had undergone treatment at Poyyanil Hospital, Kozhencherry from 3.12.2001 to 8.12.2001 as an inpatient for the treatment for headache/eltimoid sinusitis and sphenoid sinusitis and had spent an amount of Rs.7,495-38 for her treatment. After the treatment, her husband made a claim for the expenses incurred for the treatment before the opposite parties who repudiated the said claim by Ext.A2 repudiation letter stating that the diseases are pre-existing. The complainant also produced a medical certificate from Poyyanil Hospital, Kozhencherry, Ext.A3, showing that she was undergone treatment at Poyyanil Hospital from 3.12.2001 to 8.12.2001 as inpatient which also shown that she was not treated for sinusitis earlier. Therefore, she is entitled to get the treatment expenses from the opposite parties as she had a valid medi-claim policy and she prays for allowing the complaint.<br /> <br /> 8. In cross-examination, she denied that the disease for which she had undergone treatment at Poyyanil Hospital is not a pre-existing disease. She also deposed that she had never gone to Poyyanil Hospital before 8.12.2001 for taking any treatment for headache or sinusitis. <br /> <br /> 9. For the opposite parties, the third opposite party was examined as DW1. DW1 deposed before this Forum that, on getting the claim form from the complainant’s husband, they have deputed an investigator who reported that the complainant had undergone treatment for the same disease even before taking the policy. They have repudiated the claim on the basis of the investigation report, as it is a pre-existing disease. In cross-examination, DW1 deposed that they had repudiated the claim only on the basis of the investigation report. The said investigation report reveals that the complainant’s disease was a pre-existing disease and they gathered this fact from Dr. Stephen George of Poyyanil Hospital, Kozhencherry. <br /> <br /> 10. In this case, the main dispute is that the disease of the complainant was pre-existing which is not covered under the medi-claim policy. In order to prove the complainant’s case, Exts.A1 to A4 were marked. Ext.A1 is the policy certificate, Ext.A2 is the repudiation letter, and Ext.A3 is the medical certificate. The opposite parties have not opposed or challenged these exhibits. As per the above said exhibits, the complainant had a valid medi-claim policy and she had undergone treatment for headache and sinusitis and the said disease was not pre-existing at the time of taking the medi-claim policy. Further, the opposite parties have not made any attempt to discredit the veracity of Ext.A3 medical certificate. Though they have a specific contention that the disease was pre-existing, they have not produced the investigation report or they have not examined the investigator or the doctor who treated the complainant. Moreover, in cross-examination, DW1 clearly stated as follows when Ext.A3 was shown to him. “ CXn last line –  she was not treated for sinusitis earlier here F¶v ]dªn«ps­¶v hmZn ]dbp¶p? F\n¡v \ntj[n¡m³ ]änÃ.” There is no dispute regarding the validity of the policy, treatment, medical expenses the contention, pre-existing disease is not proved by the opposite parties. Therefore, the complainant had proved the deficiency of service of the opposite parties. In the circumstances, this complaint can be allowed with cost and compensation.<br /> <br /> 11. In the result, this complaint is allowed, thereby the complainant is allowed to realise Rs.7,495/- (Rupees Seven thousand four hundred and ninety five only) with interest at the rate of 10% per annum from the date of filing of this O.P. till this date from the opposite parties. The complainant is also allowed to realise Rs.2,000/- (Rupees Two thousand only) as compensation for the deficiency of service with a cost of Rs.500/- (Rupees Five hundred only) from the opposite parties. The opposite parties are directed to pay the amounts so awarded in favour of the complainant within 2 months from the date of receipt of this order, failing which the interest will follow at the rate of 12% per annum till whole payment. <br /> <br /> Declared in the Open Forum on this the 5th day of September, 2008.<br /> (Sd/-)<br /> Jacob Stephen,<br /> (President)<br /> <br /> Smt. C. Lathika Bhai (Member) : (Sd/-)<br /> Sri. N. Premkumar (Member) : (Sd/-)<br /> <br /> Appendix:<br /> Witness examined on the side of the complainant:<br /> PW1 : Susamma Thomas.<br /> Exhibits marked on the side of the complainant:<br /> A1 : Medi claim insurance policy.<br /> A2 : Repudiation letter dated 6.3.2002 issued by the opposite party to the <br /> complainant.<br /> A3 : Medical Certificate dated 14.3.2002 issued by Dr. Stephen George <br /> M.D., Poyyanil Hospital, Kozhencherry.<br /> A4 : Photocopy of the policy schedule.<br /> Witness examined on the side of the opposite parties:<br /> DW1 : R. Radhakrishnan Nair.<br /> Exhibits marked on the side of the opposite parties:<br /> B1 : Claim Form.<br /> B2 series : Medical bills (14 in number) for Rs.7,495-38.<br /> B3 : Discharge Summary issued by Poyyanil Hospital, Kozhencherry.<br /> <br /> (By Order)<br /> <br /> Senior Superintendent.