<br /> <br /> <br /> <br /> By SRI. K. VIJAYAKUMARAN ACHARY, PRESIDENT.<br /> <br /> This is a complaint filed for realization of Rs.164848/- being the Insurance claim.<br /> <br /> The averments in the complaint can be briefly summarized as follows:<br /> <br /> The complainant is a policy holder under the Kudumba Arogya Policy bearing No.2000/47/761400/84568 [760901] of the respondent. The period of coverage of policy was five years effective from 31.3.3000 till 30.3.2005. The policy is intended for the pravasi Indians and their family members. The complainant having undergone treatment for vascular necrosis of femoral head with secondary osteoarthrosis [R] hip at Amritha Institute of Medical Sciences and Research Centre, Kochi on 29.10.2003. The complainant their upon preferred claim form along with the medical certificate etc which was repudiated by the 1st opp. Party as per letter dated 28.11.2003 on the ground that the complainant was suffering from the above disease for the past 4 years and the same is excluded under clause VII [1] of the terms and conditions in the Pravasi Suraksha Kudamba Arogya Policy . Hence the complaint.<br /> <br /> The opp.party filed a version contending, Interalia, that the complaint is not maintainable either in law or on facts. The complainant is suppressing the material facts regarding the case. The definition complaint, complainant, Consumer Dispute service as defined in section 2 [1] of the Consumer Protection Act do not cover the claim made out in the complaint. The opp.party has issued a Pravasy Suraksha Kudumba Rogya Policy to the complainant and her other family members for a period from 31.3.2000 to 30.3.2005. As per the policy issued by this opp.party, the complainant is eligible to get medical reimbursement to a maximum Rs. 1 lakh subject to the terms and conditions. The policy was issued trusting on the declaration given by the insured from the proposal form submitted by them and taking it as a declaration of utmost good faith as per the condition No VII [1] of the policy any disease existing at the time of inception of policy is an excluded risk. As per the claim form submitted from the complainant that the disease was detected four years before and she was suffering from the disease associated with her right hip for the last four years. The complainant admitted in the claim form that that, she had been under the treatment of Dr. Vikraman Pillai of A.M. Hospital, Karunagappally, for the last four years, who detected her disease four years back. It is a very same doctor who referred her to Amruta Institute of Medical Science and Research Centre, Kochi the medical certificate issued by the Dr. Jayachandran who treated her at the Amruta Institute of Medical Science and Research Center it has specifically stated that the complainant has been suffering from the disease for the last four years as on the 1st consultation with him. The symptoms of the disease were aged four years which gradually progressed in to a chronic stage. It is therefore a vivid fact that the complainant was suffering from the disease of Vascular necrosis of femoral head with secondary osteoarthrosis right hip for a minimum period of four years since her admission in the Amrutha Institute Medical Science. So it is clear that the complainant was suffering from the disease prior to the commencement of the policy . The complainant deliberately suppressed from the opp.party. Therefore the claim was repudiated by this opp.party on sound, legal and solid grounds. Hence the opp.party prays to dismiss the complaint.<br /> <br /> Based on the contentions the following points arise for consideration are: <br /> <br /> <br /> [1] Whether there is deficiency in service on the part of the opp.parties<br /> [2] Reliefs and costs. <br /> <br /> <br /> <br /> For the complainant PW.1 is examined. Ext.P1 to P8 are marked.<br /> <br /> For the opp.party DW.1 is examined. Ext. D1 to D5 are marked..<br /> <br /> <br /> <br /> <br /> Point – 1 & 2<br /> <br /> <br /> <br /> It is not disputed that the complainant has taken Ext.D1 policy and that the policy was subsisting when the complainant had undergone treatment from 28.10.2003 to 10.11.2003 at the Amrutha Institute of Medical Science and Research Centre, Kochi. The complainant submitted Ext.D2 claim which was repudiated by the opp.party as per Ext.D5 on the ground that the illness for which the complainant had undergone treatment is a pre existing one which comes within the exclusion clause VII [1] of Ext.D1 policy<br /> <br /> Ext.D1 is the policy and clause VII of the condition deals with exclusion and VII [1] eals with pre existing diseases. Now the question is whether the illness for which the complainant had undergone treatment is a pre existing one or not According to the opp.party Ext. D2 to D4 would establish that the illness was a pre existing one. Both in Exts D3 Discharge Summary and Ext.D4 Medical Certificate issued by the treated Doctor shows that the complainant was suffering from the illness 4 years back from the date of treatment. It is obvious that this information was given to the doctors by the complainant herself. In Ext.D2 claim form the complainant herself has stated in column No.5 [b] that she was suffering from the illness 4 years back. Copy Ext. D2 was produced by the complainant herself and marked as Ext.P4. Even ignoring Exts. D3 and D4 with regard to the duration of existence of disease Ext.D2 which was filled in and submitted by the complainant herself cannot be ignored.<br /> <br /> The learned counsel for the complainant argued that the complainant went to A.M. hospital, Karunagappally for the first time only on 11.4.2000 and at the time when policy was taken she had no such ailments. He would further argue that even though in Exts. D3 and D4 it is mentioned that the complainant was having hip disorder for 4 years it could not be interpreted that the complainant was fully aware of the nature and magnitude of her disease previously and that it is improper misinterpret medical certificate for rejecting the claim that argument cannot be accepted. Even Exts. D3 $ D4 are ignored the statement in Ext.D2 claim form cannot be ignored. There is no case that it is a mistake. In these circumstances we are of the view that the repudiation of the claim under exclusion clause VII [1] is proper There is no deficiency in service on the part of the opp.party. Point found accordingly.<br /> <br /> <br /> <br /> In the result the complaint fails and same is hereby dismissed.<br /> <br /> <br /> <br /> Dated this the 26th day of April, 2008.<br /> <br /> <br /> <br /> <br /> I n d e x<br /> <br /> List of witnesses for the complainant<br /> PW.1. – Chandrika<br /> <br /> List of documents for the complainant<br /> P1. – Treatment Certificate<br /> P2. – Medical report<br /> P3. – Repudiation letter<br /> P4. – Claim Form.<br /> P5. – Certificate of of Dr. Jacob Varghese of AM Hospital<br /> P6. – Medical bills<br /> P7. – Certificate of Insurance and Receipt voucher<br /> P8. – Policy conditions.<br /> <br /> List of witnesses for the opp.party<br /> DW.1.A.R. Lekshmy Narayanan<br /> <br /> List of documents for the opp.party<br /> D1. – Policy and conditions<br /> D2. – Original claim form<br /> D3. – Discharge summary from Amrutha Hospital<br /> D4. – Medical certificate issued by Amrutha Hospital<br /> D5. –Repudiation letter.<br /> <br /> <br />