By Smt. E. Ayishakutty, Member,

1. Complaint in brief:-

Complainant as the holder of Mediguard Policy vide No.101000/48/05/12/00001676 of the United India Insurance Company Ltd. From 04-3-2006 to 03-03-2007. He was under treatment of Dr. Shajid in Maanu Memmorial Hospital, Manjeri from 15-6-2006 for suffocation. Then on 26-7-2006 complainant was admitted in the hospital for Nasal Septum surgery. After surgery he was discharged on 29-7-2006. Then he submitted claim application for Medi claim with the medical report to opposite party. But opposite party rejected the claim by stating that complainant was undergone the treatment for deviated Nasal Septum and it is congenital illness and congenital illness is excluded from the coverage of Mediguard Policy. So complainant filed this petition before the Forum alleging deficiency of service on the part of opposite party.

2. Complainant prays Rs.6,995/- (Rupees Six thousand nine hundred and ninety five only) as the claim amount and Rs.5,000/- as compensation for the mental agony.

3. Opposite party filed version. He admits the policy of the complainant. Opposite party states that he has examined the claim with details. He referred the claim records to Mediclaim Analysist for verification and obtained report from them. Opposite party states that the disease for which the complainant claims to have undergone treatment was congenital. The congenital disease was exempted from the Mediclaim Policy as per exclusion clause 4.2. So the claim has repudiated by opposite party and it has no ambiguity. There is no need to refer the complainant before the panel of doctors as per the policy condition 42a. The complainant has not entitled to get any amount from opposite party. Hence the complaint is to be dismissed with cost of opposite party.

4. Complainant filed affidavit and documents for evidence. Ext.A1 to A7 marked on the side of him. Opposite party filed counter affidavit. No documents filed on behalf of him. No oral evidence adduced both sides.

5. The main points to consideration are whether there is any deficiency on the part of opposite party. If so what is the relief and costs.

6. Complainant was Mediguard policy holder and he was treated for the illness of Deviated Nasal Septum. Then a surgery was conducted under Dr. Shajid at Maanu Memmorial Hospital at Manjeri on 27-7-2006. These are all admitted facts. The only dispute arose here is whether the illness of Deviated Nasal Septum suffered by the complainant is congenital and it was existing at the time of policy proposal or not. Opposite party says it was pre-existing and so he rejected the claim. Opposite party states that he referred the claim with all records to the Medi claim Analysist for clarification. Opposite party says the report of the Analysist is very clear and no ambiguity and so there is no need to refer the complainant before the panel of doctors. But the medical report issued by the treated Dr. Mr. Shajid shows that the illness of the complainant which he has treated was not congenital. He further says in his Medical Report as marked as Ext.A7 that the insured is suffering this disease for the last one and half month prior to the Nasal Septum surgery. Complainant was hospitalised only on 26-7-2006 and he has taken the policy on 04-3-2006. But opposite party has not accepted this Medical report, he rejected the claim on the basis of the Analysist report obtained from Medi claim Analysists. But opposite party has not produced this report before the Forum for evidence. The only documental evidence before the Forum to clarify whether the illness of the complainant is pre-existing or not is Ext.A7, the Medical Report. This Medical Report was prepared by the treated doctor on verifying the treatment record in the hospital. Opposite party has not produced any documental evidence or expert opinion to defend Ext.A7, the Medical Report produced by the complainant. Therefore from the above narrations we conclude that the denial of the claim without valid reasons is deficiency in service on the part of opposite party and so opposite party is liable to pay the claim amount of Rs.6,995/- to the complainant.

7. In the result the complaint is allowed and opposite party is directed to pay the amount of Rs.6,995/-(Rupees Six thousand nine hundred and ninety five only) with 9% interest per annum with effect from the date of complaint till realisation. Opposite party also pay an amount of Rs.1,000/- (Rupees one thousand only) as costs. The order shall comply with in one month from the date of receipt of copy of this order.

Dated this 15th day of July, 2010.

Sd/-

C.S. SULEKHA BEEVI, PRESIDENT

Sd/-

MOHAMMED MUSTAFA KOOTHRADAN, Sd/-

MEMBER E. AYISHAKUTTY, MEMBER

APPENDIX

Witness examined on the side of the complainant : Nil

Documents marked on the side of the complainant : Ext.A1 to A7

Ext.A1 : Medi Guard Policy No.101000/48/05/12/00001676 issued by opposite party to complainant.

Ext.A2 : Photo copy of the Discharge card dated, 29-7-2006 from Maanu Memorial Hospital, Manjeri to complainant.

Ext.A3 : Photo copy of the in-patient medicine chart from Maanu Memorial Hospital, Manjeri to complainant.

Ext.A4 : Registered letter by opposite party to complainant.

Ext.A5 : Photo copy of the lawyer notice dated, 15-6-2007 by complainant's counsel to opposite party.

Ext.A6 : Registered with AD reply notice dated, 09-7-2007 from opposite party's counsel to complainant's counsel.

Ext.A7 : Photo copy of the Medical report from Maanu Memorial Hospital, Manjeri to opposite party.

Witness examined on the side of the opposite parties : Nil

Documents marked on the side of the opposite parties : Nil

Sd/-

C.S. SULEKHA BEEVI, PRESIDENT

Sd/-

MOHAMMED MUSTAFA KOOTHRADAN, Sd/-

MEMBER E. AYISHAKUTTY, MEMBER