O R D E R Sri. Santhosh Kesavanath P., President. Case of the petitioner's is as follows: The petitioner had taken a policy of PRAVASI SURAKSHA KUDUMBA AROGYA SCHEME of the opposite party on 26..12..2000. The said policy is valid up to 25..12..2005.and has a coverage of Rs. 2,00,000/-. Petitioner during the time of the policy, ie. in March 2005, was suddenly hospitalised in Amritha Institute of Medical Science, Ernakulam. The petitioner had undergone a major operation for Coronary Artery Diesease and an amount of Rs.1,87,746/- was incurred to him for the treatment. The petitioner on 1..4..2005 preferred claim for reimbursement of the amount covered by the policy, along with document for processing the claim, Since there was no response from the first opposite party for 3 months the petitioner sent a registered notice to the second opposite party. On 29..7..2005 the first opposite party intimated the petitioner that -2- claim of the petitioner was repudiated. The reason for repudiation of the claim stated by the opposite party was that disease of the petitioner was pre-existing, at the time of issuance of policy. According to the petitioner the said allegation is baseless and there was no finding in medical records that the heart disease was caused due to existed hypertention. The petitioner states that due to the mistake on the part of the authorities of the hospital in the discharge summory of the petitioner, the petitioner was shown hypertensive for last 15 years. Soon after notice in mistake the petitioner approached the hospital authorities. The hospital authorities after verifying the records corrected the discharge summary sheet. The petitioner submitted the corrected records to the second opposite party and they are not willing to acept the claim of the petitioner. According to the petitioner repudiation of the claim on flimsy ground is a clear deficiency in service. So, he prays for an order, directing the opposite party, to reimburse an amount of Rs. 1,87,476/-, the amount incurred by the petitioner for his treatment, along with 12% interest. He claims compensation in the tune of Rs. 10,000/- and Rs. 2,000/- as cost of the proceedings. The opposite parties filed version contenting that the petition is not maintainable. According to the opposite party the petitioner has not signed on the petition. So it is to be dismissed without going in to merits. The opposite party contented that the claim was legally repudiated . On scrutiny of the records submitted by the petitioner it was found that the petitioner was hypertensive and dyslipidemic since 15 years. Since hypertension and dyslipidemia were pre-existing at the time of availing the policy. As per clause No VII (1) of the policy certificate the opposite party shall not be liable. They contented that -3- at the time of application for availing the policy the petitioner suppressed the facts that he had hypertension and dyslipidemia. Further more, the opposite party contented that as per the opinion of their pannel doctor, Dr. Mathew Parackal, both the above said hypertension and dyslipidemia are risk factors which can predispose for coronary artery disease. So, the opposite party contented that the original discharge summary issued by AIMS had truly stated that the petitioner was hypertensive and dyslipidemic for 15 years. According to the opposite party the petitioner fabricated another discharge summary purporting to be issued by AIMS stating that petitioner was a hypertensive since 4 years. So, the opposite party had not considered the said documents produced by the petitioner. The opposite party contented that the repudiation of the claim is legal and no deficiency in service can be attributed against the opposite party so, they pray for a dismissal of the petition with their cost. Points for deterinations are: i) Whether there is deficiency in service on the part of the opposite party? ii) Reliefs and costs. Evidence in this case consists of affidavit filed by both parties and Ext. A1 to A10 documents on the side of the petitioner and Ext. B1 to B4 documents on the side of the opposite parties. Point No. 1 Material question to be decided is whether the repudiation of the claim of the petitioner is legal or not. The petitioner produced the repudiation letter dtd.29..7..2005 the said document is marked as Ext. A2. In Ext. A2 the reason for repudiation is stated as -4- that on scrutiny of the claim papers submitted by the petitioner in the discharge summary issued by AIMS, Kochi it has been stated that the patient is hypertensive since 15 years and is also dyslipidemic. So, the opposite party sent papers to their panel doctor for the expert opinion and the panel doctor reported that both hypertension and dyslipedemic are risk factors which can attribute coronory artery disease. So as per clause 61 of the policy the claim of the petitioner cannot be entertained. The petitioner produced discharge summary, issued from the AIMS hospital, the said document subject to proof is marked as Ext. A3. In Ext. A3 it is mentioned that the insured is hypertensive for 4 years and is dyslipedemic. The opposite party produced the discharge summary and said documents is marked as Ext. B3. In Ext. B3 it is stated that the insured is hypertensive since 15 years and is dyslipedemic. So, the learned counsel for the opposite party argued that the Ext. A3 documents is a fabricated documents and repudiation of the claim on perusal of the Ext. B3 documents is legal and no deficiency can be attributed against the opposite party. The counsel for the petitioner argued that the petitioner submitted the duly corrected discharge summary to the opposite party and that was not considered by the opposite party. The Forum as per the request of the petitioner issued a questionaire to the concerned physician who treated the insured and the reply was received. The said document is marked as Ext. C1. In Ext. C1 the doctor stated that he himself corrected the discharge summary in the history portion. We are of the opinion that the opposite party has a bounden duty to enquire about the matter after submission of a corrected discharge summary. So, the non enquiry and repudiation in our view is a clear deficiency of -5- service. The opposite party produced the opinion of expert doctor in their panal. The said document is marked as Ext. B4. In Ext. B4 the doctor stated that hypertension for 15 years is a risk factor for causing heart disease. But from C1 it can be seen that the petitioner has caused hypertension for the last 4 years. We are also of the opinion that unless and until the insured undergon hospitalisation for few days or undergone operation in the immediate past before taking the insurance policy, or at no other stage is not supposed to disclose about the day-to-day life as diabetic, hypertension or chest pain etc. The said problems are normal ways of life that are controlable on day-to-day basis. Pre-existing disease, in our view, is one for which the insured should have been undergone hospitalisation or undergone long treatment or operation otherwise for a layman this day- to-day normal problems are not to be disclosed as even otherwise medical terminology of a such problems is difficult to understand and know. Further more entering in to contract for this policy, by paying the premium, the utmost good faith of an insurer is that he will be protected in the event of his untimely disease. But the facts of the insurance company in eviding the claim prefered by an insurer on concocted grounds is not acceptable. So, point No. 1 is found accordingly. Point No. 2 In view of the findings in point No. 1, petition is to be allowed and petitioner is entitled for the reliefs sought for. So, the opposite parties are ordered to reimburse medical and hospital bill for an amount of Rs. 1,87,746/- to the petitioner with 8% interest for the said amount from the date of repudiation till realisation. The opposite parties are also ordered to pay an amount of Rs. 1,000/- as cost of the proceedings. Since -6- interest is allowed, no compensation is ordered. Order shall be complied with within 30 days of receipt of this order. Dictated by me transcribed by the Confidential Assistant corrected by me and Pronounced in the Open Forum on this the 29th day of August, 2008.
......................Bindhu M Thomas ......................Santhosh Kesava Nath P
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