By Smt. Saji Mathew, Member:-

The gist of the case is as follows:-

The Complainant is the policy holder of Reliance Health wise policy issued by the 1^st Opposite Party as policy No. 282510033478. The 2^nd Opposite Party is the third party administrator of the 1^st Opposite Party and the Complainant paid policy amount through the 3^rd Opposite Party. The Complainant joined Reliance Health wise Policy – Gold, family floater scheme on 14.11.2007 by paying Rs.1,654/-. As per the scheme, the policy cover maximum four persons of the family consisting of Complainant, wife, and two children under the age of 21 years.

2. On 09.07.2008, the Complainant's daughter Namitha Jose aged 12 years was admitted in the Medical College Hospital, Calicut for the treatment of uncompensated adolescent idiopathic scoliosis (Rt) sided Thorasic curve. A surgery was made on 26.7.2008 and she was discharged on 22.08.2008. The expense for treatment comes near One Lakh and the Complainant made a claim before the Opposite Party. The 2^nd Opposite Party rejected the claim stating that the disease was pre-existing and not admissible as per terms and conditions of policy. In the claim form, the doctor who has treated the patient has stated that the duration of disease is only three months. The disease appeared only after the commencement of policy. Hence, it is deficiency in service on the part of the Opposite Parties to pay the insurance amount. Therefore, the Complainant prays for an order directing the Opposite Parties to pay an amount of Rs.94,371/- with 12% interest from the date of 10.9.2008. The Complainant also prays for a compensation of Rs.20,000/- and other costs.

3. The Opposite Parties appeared and filed their versions. The 1^st Opposite Party admitted the policy and the claim. The surgery was carried out within 8 months of the policy coverage. As per the Complainant the ailment is three months old. But as per the documents submitted by the Complainant, it is observed that the ailment adolescent scoliosis (lateral curvature of the spine with vertebral rotation) is not a recent development and takes many years to present with above features mentioned. As per the policy conditions, the Opposite Parties are not liable to make payment under this scheme in respect of medical expenses incurred by or for the insured person in connection with any disease which have been in existence at the time of proposing the insurance. Pre-existing condition means any sickness or its symptom which existed prior to the effective date of insurance whether or not the insured person has knowledge that the symptoms were relating to sickness. Based on medical opinion and investigation report, Opposite Party has no other way than repudiating the the claim. The Opposite Party also disputes the amount spent for medical expenses as alleged in the complaint. There is no deficiency in service on the part of the Opposite Party, and 1^st Opposite Party prays for an order dismissing the complaint.

4. The 2^nd Opposite Party also stated the very same matters as are stated by the 1^st Opposite Party in their version. The 3^rd Opposite Party stated that Muthoot Finance Corporation is one of the corporate agency of 1^st Opposite Party. They have tie up in generating sales for them. Service like policy insurance and customer service is provided by them. Claim settlement for mediclaims are handled by their third party Administrators. In this case, 2^nd Opposite Party is the T.P.A. Therefore 3^rd Opposite Party request to be exempted from the proceedings.

5. The Complainant was examined as PW1. Documents were marked as Ext.A1 to A6 series. One witness also was examined on the side of the Complainant as PW2. No evidence was adduced on the side of the Opposite Parties. No documents were marked for the Opposite Parties.

6. The matters to be considered are:-

1. Whether there is any deficiency in service on the part of the Opposite Parties?

2. Whether the Complainant is entitled to any relief?

7. Point No.1:- The main contention of the Opposite Parties is that the disease regarding which the claim is made is pre-existing at the inception of policy. The policy coverage starts from 14.11.2007. The surgery was done on 26.7.2008. As per Ext.A5 the duration of the disease is three months. The Opposite Parties themselves admit that the surgery was done in the 8 month of policy. The Opposite Parties allege that as per the documents submitted by the Complainant, it is observed that the ailment adolescent scoliosis (lateral curvature of the spine with vertebral rotation) is not a recent development and takes many years to present with above features mentioned. But on perusal of Complainant's document no such opinion is seen made. The Opposite Parties have not produced any documents to show that the disease was pre-existing. They have not examined any witness to explain that the disease adolescent scoliosis takes many years to present itself with such features as are seen in the patient in this case. PW2 has stated that by assessing Ext.A5 the disease might have started long back. The Opposite Parties have not made any investigation regarding the school attendance of the patient or called for the school records. That would have shown commencement and duration of the disease. On the other hand, the Complainant has produced Ext.A6 series, the certificates won by the the patient for dancing which shows that the girl was normal in the earlier months. So, on perusal of the documents produced by the Complainant, there is nothing to conclude that the disease was pre-existing. The Opposite Party have not adduced any evidence or produced any documents. So, point No.1 is found in favour of the Complainant.

8. Point No.2:- Here, the Complainant has claimed Rs.94,371/- for medical expense. The sum insured is One Lakh. The Complainant has not produced any bills or receipts to show that an amount of Rs.94,341/- was incurred as medical expense. The Complainant has stated that he has presented all bills and receipts with the Opposite Parties along with the claim. The Opposite Party has not denied that statement. They have not produced documents to show that the Complainant's medical expense was less than 94,371/-. In such circumstances, the Opposite Party is liable to pay the entire amount claimed.

Therefore, the complaint is partly allowed and the Opposite Parties are directed to disburse the insure claim for Rs.94,371/- (Rupees Ninety Four thousand Three hundred and Seventy One only) with 10% interest per annum on the amount from the date of this order till payment. No order as to cost or compensation.

Pronounced in open Forum on this the day of 29^th April 2010.

PRESIDENT: Sd/-

MEMBER : Sd/-

MEMBER : Sd/-

A P P E N D I X

Witnesses for the Complainant:

PW1. Jose. K. M, Agriculture.

PW2. Dr. K.L. Raju. Orthopedic Consultant, Vinayaka Hospital,

Sulthan Bathery.

Witnesses for the Opposite Parties:

Nil.

Exhibits for the Complainant:

A1. Reliance HealthWise Policy Schedule.

A2. Letter. dt:21.3.2009.

A3. Copy of Reliance HealthWise Policy Claim Form. dt:10.09.2008.

A4 series (2 Nos.) Photocopy of Referral OP Ticket.

A5. Copy of Discharge Card.

A6 series (2 Nos.) Copy of Certificate.

Exhibit for the Opposite Party:

Nil.