Sri.K.N.Radhakrishnan, Member.

The case of the complainant is as follows:

The complainant had a mediclaim policy from 26.12.2001. Thereafter the policy was renewed from time to time upto 11.4.2006. Admitedly the policy was renewed from time to time with breaks intersei. According to the complainant the policy was a continuing one and not a fresh policy. Each policy had mentioned the previous policy Number. So the policy is continuing one and not a fresh policy. On 1.6.2005 during the life of the policy renewed, the complainant had undergone surgical operation at Lakeshore Hospital, Ernakulam for relief of suffering from pain and other difficulties due to the steel plants. An amount of Rs.22,297/- had been spent by the complainant for the surgical operation as

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hospitalisation charges. The removed steel plants were implanted in the body of the complainant during the Ist policy due to a road traffic Accident.

The removal of implant was necessitated to avoid the pain and suffering, out of the growth of the bone tissues after the insertion of those plants. The complainant claimed the amount of Rs.22,297/- with original bills obtained from the hospital. The opposite party repudiated the claim of the complainant. Stating that the claim of the complainant was pre-existing and the same was intimated through their 3^rd party Administration Department ie.T.T.K. There was a deficiency in service on the part of the opposite party in not settling the claim. The complainant is entitled for getting the claim amount as per policy. Hence this complaint.

The notice was served with the opposite party. They appeared and filed their version contending as follows. The complainant himself had admitted in the complaint that each and every policy was renewed by him only after break of various days as stated in the complaint. The allegation that each of the subsequent policies availed by the complainant from the Ist policy dated 26.12.2001 were the continuation of the Ist policy is wrong. The complaint was well aware that the policy dated 12.4.2005 was not a continuation of the existing policy but only a new separate policy. This policy was a freshly incepted one. The policy of the complainant was contracted after a break of 104 days after the expiry of the earlier policy has rendered the injury and treatments of the complainant to be pre-existing and not considered the injury and treatments of the complainant to be pre-existing and not considerable for any payments. As admitted by the complainant and as that can be seen from the allegations in the

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complaint the surgery undergone by the complainant was for removal of the implant that was fixed during the existence of the policy of which the period expired on 29.12.2004. There was no deficiency in service on the part of the opposite party. The complainant was not entitled for any reliefs as claimed. Hence the complaint may be dismissed with costs:

The complainant filed Proof Affidavit and documents which are marked as exhibits A1 to A6.The opposite party filed Proof Affidavit.

Heard Both sides. We have gone through the complaint, version, documents and evidence of both sides. The case of thecomplainnt is that the opposite party has not allowed the claim with untenable contentions. According to him he was entitled for the claim because the hospitalisation and treatment expenses has not within the policy period. As far as the complainant is concern the claim amount was not a previous ailments treatments. The opposite party has taken a contention that the disputed policy was not a continuing one. According to the opposite party the policy issued to the complainant with a break of 104 days. So, accordingly the policy was a new one and not a continuing one. Admittedly the complainant had a medi-claim policy from 2001 onwards. The alleged claim was on account of removal of implaint which was already fixed. The implaint was fixed on the complainant during the previous policy. The expenses incurred by the implaint fixation was already settled by the opposite party during the previous policy. So accordingly the disputed claim of the complainant was not a Fresh disease. The alleged claim was due to the expenses incurred by the complainant for the removal of implant fixation. The implant fixation was done only for the purpose of re-union of the damaged bone or damaged organs. After the re-union of the damaged bone

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or damaged organs the implant should be removed for the smooth functioning of the bone or organs. Moreover the opposite party has not a case that the treatment expenses of the complainant was not for the period during the policy was in break. We have gone through the available documents and evidences the disputed claim of the complainant was only the expenses incurred for the removal of implant fixation. The opposite party has already settled the claim of the complainant for the expenses incurred for the treatment of implant fixation. The expenses incurred for the removal of implant fixation would also be settled by the opposite party. Hence we are of the opinion that the case of the complainant is to be allowed.

In the result the complaint is allowed as follows: We direct the opposite party to pay the claim amount to the complainant as per policy and pay Rs.1000/- as compensation for inconveniences and pay Rs.750/- as costs of these proceedings. The order shall be complied with within a period of one month from the date of receipt of this order.