O R D E R SRI. JIMMY KORAH (PRESIDENT) The case of the complainant is that he was a holder of medi-claim policy of National Insurance Company from 2004 onwards. He was treated at Manipal Hospital at Bangalore for Anterior Communicating artery aneurysm hypertension. He had spent Rs.1,15,000/-. The opposite party repudiated the claim of the complainant on the reason that he has pre-existing disease. The repudiation is without any valid reasons. Hence he challenges the repudiation of the opposite party and filed this complaint. 2. Opposite party filed version stating following contentions. As per the treatment records he had a stroke and had been on treatment and also known hypertensive for the last two years. Hence as per the terms and conditions of the policy repudiation is true and correct. So the petition is only to be dismissed. 3. Considering the contentions of the complainant and opposite party this Forum raised the following issues:- a. Whether the complainant is entitled for claim amount and compensation from the opposite party establishing the deficiency as averred in the complaint? 4. Complainant filed proof affidavit and cross examined by the counsel of the opposite party. Further he produced 3 documents and marked as Exts. A1 to A3. On the side of the opposite party they produced and marked 8 documents and marked as Exts.B1 to B8. 5. The sole question is to be considered is that hyper tension and alleged stroke has contributed to the diseases caused to the complainant in the disputed period. It is admitted that complainant is a policy holder from 3.6.2004 onwards. The claim preferred by the claimant is on the renewal period of the policy. This is a continuing policy. From 29.1.2006 onwards he admitted at Manipal Hospital Bangalore. If he has caused a stroke before 1 ½ years then it would have been in the month of July, 2004. If it is so, then it was within the earlier period of the policy. But no claim preferred. Further there is no illegality. Since the present disease is continuous one of the earlier stroke, even then it was happened after taking the policy. Opposite party has no case that complainant preferred a claim on this aspect. Then the next case of the opposite party is that complainant is a hypertensive patient for the last two years. The opposite party has not produced any document to substantiate the contention that hypertension is the cause for the present disease. No expert opinion produced by the opposite party. Further proposal form submitted by the complainant has not produced before this Forum. In the absence of these documents and evidence it cannot be accepted the contention of the opposite party. On the above said reasons we find that there is no policy violation and there is a deficiency of service on the part of the opposite party and the repudiation dated 30.9.2006 is illegal and erroneous. 6. Complainant produced Ext.A3 – copy of the final bill issued by the Manipal Hospital. In which it is stated that bill amount is Rs.1,12,088/-. On the other hand opposite party produced Ext.B5. In which it is stated that bill amount is Rs.1,05,721/-. But the complainant claimed only Rs.50,000/-. Hence we directed to the opposite party to pay an amount of Rs.50,000/- (Rupees fifty thousand only) to the complainant. Considering the facts and circumstances of this case there is no order on cost and compensation. Opposite party is directed to pay the said amount within 30 days from the date of receipt of this order. Complaint allowed. Pronounced in open Forum on this the 29th day of May, 2008. Sd/- SRI. JIMMY KORAH: Sd/- SRI. K. ANIRUDHAN: Sd/- SMT. N. SHAJITHA BEEVI: APPENDIX:- Evidence of the complainant:- PW1 - Sathyapalan Pillai (Witness) Ext.A1 - Photo copy of the policy receipt Ext.A2 - Photo copy of the identification slip Ext.A3 - Photo copy of the Hospital Bill Evidence of the opposite party:- Ext.B1 - Individual medi claim policy Ext.B2 - Claim form Ext.B3 - Pre authorization details Ext.B4 - Discharge Summary Ext.B5 - Provisional bill for Rs.4279/- Ext.B6 - Letter dated 30.9.2006 Ext.B7 - Adv. Notice dated 15.12.2006. Ext.B8 - Copy of the Reply notice dated26.2.2007. // True Copy // By Order Senior Superintendent To Complainant/Oppo. party/S.F. Typed by:-pr/- Compared by:-
......................JIMMY KORAH
......................K.Anirudhan
......................Smt;Shajitha Beevi | | 
