By Sri. K. Gheevarghese, President:<br /> <br /> The complaint filed under section 12 of the Consumer Protection Act.<br /> <br /> <br /> The complaint in brief is as follows.<br /> <br /> The Complainant and the members in the family are insured by the 2nd Opposite Party under the scheme of group heath insurance policy. The policy numbered 100312/4605 for Rs. 20,000/- is the policy in which the Complainant and the family members covers the risk. The Complainant's daughter was affected of a disease on 25.5.2007 and in connection with that the Complainant's daughter was admitted MIMS Hospital Calicut and had undergone treatment there. The amount spent for the treatment was Rs.13,604/- and for other expenses Rs.5,000/- was also spent by the Complainant.<br /> <br /> 2. The Opposite Parties are responsible to pay the treatment charges and other expenses which are covered under the terms and conditions of the policy. Instead of giving the treatment charges indemnified by the policy the Opposite Parties evaded from the responsibility. A lawyer notice was sent to the 2nd Opposite Party demanding the expenses which is to be refunded by the Opposite Party. In reply to the notice the 2nd Opposite Party informed that the claim form was not given to them. The Complainant subsequently sent the claim form along with other documents by registered post on 29.8.2007. Even after the receival of the claim form and the connected documents the 2nd Opposite Party was not ready to give the Complainant the benefits of the scheme. There may be an order directing the Opposite Party to give the Complainant Rs. 13,604/- the amount paid in the hospital along with other expenses Rs.5,000/- and also the cost of this complaint. <br /> <br /> 3. The 1st Opposite Party filed version on their appearance the sum up of the averments in the version is as follows. The 1st Opposite Party admitted the group health insurance policy of <br /> the Complainant issued by United India Insurance Company limited, Thamarassery to the members of the Srayas Sulthan Bathery. The Complainant made a claim for the treatment of his daughter Shelin Varghese for the expenses of treatment for nasal hypertrophy which was done from MIMS Hospital, Calicut. The question No.6 in the claim form which is on the date of injury sustained or of disease/illness contracted there the answer given is on 30.5.2006 the policy commences from 31.7.2006. The application sent by the Complainant was returned on the ground that Shelin had been undergoing illness for the past several years. The claim was repudiated because of pre-existing disease and it was suppressed at the time of inception to the policy. The Complainant is not entitled for any compensation, there is no deficiency in service and the complaint is to be dismissed with cost.<br /> <br /> 4. The 2nd Opposite Party filed version on their appearance. The gist of the contention the 2nd Opposite Party is as follows. The 2nd Opposite Party also admitted Health Insurance Policy of the Complainant No.100312/48/06/41/00000466 issued by the United India Insurance Company Limited, Thamarassery to the members of Sreyas Sulthan Bathery. The answer to the question No.6 of the claim application on the date of injury sustained or of disease/illness contracted the answer given is 30.5.2006. The policy commences on 31.7.2006. The claim application was returned to the Complainant stating that the claim was no payable. The Complainant approached the 2nd Opposite Party directly and on his enquiry it was also informed that the claimant has to give an application through the 1st Opposite Party, the Sreyas. The Complainant sent the application and other documents in registered post to the 2nd Opposite Party. On receival of the claim form an investigator was appointed to verify the hospital records and other details. It was known to the investigator that the claimant had pre-existing disease before 3 to 4 months before her inception to the policy. An another investigator was again appointed to make an enquiry in the school where the claimant studied. It was also known <br /> to the investigator and the claimant was suffering from the illness for the past several years. The Complainant's daughter had been sufferings from illness even prior to her entry in to the policy. The petition is not considerable and it is to be dismissed with cost to the 2nd Opposite Party.<br /> <br /> 5. The points in consideration are:<br /> 1.Is there any deficiency in service on the part of the Opposite Party?.<br /> 2.Relief and cost.<br /> <br /> 6. Point No.1:- The Complainant filed affidavit swearing the allegations and he is examined as PW1. Ext.A1 to A16 are marked substantiate the evidence. Opposite Parties No.1 and 2 has not tendered any oral evidence. Ext.B1 is marked to substantiate their contention. The document Ext.B1 produced by 2nd Opposite party is the claim form of Jan Arogya Bhima Policy. The question No.6 of the policy is answered as 30.5.2006 which is the answer to the question of the date of injury sustained more of disease/illness contracted. The date to commencement of treatment in question No. 9A is answered 30.5.2007 and in the same question answer to (b) 1.6.2007 is written as the date of completion of treatment. The Complainant on examination deposed that his daughter was taken to MIMS Hospital Calicut for the first time on 25.5.2007. The Complainant 's wife is a member in Sreyas. The policy covers the treatment expenses of the insured. On examination the Complainant it is stated that the answer to the question No.6 is wrongly written as 30.5.2006. Instead of writing 2007, 2006 is written. The claimant was admitted in MIMS Hospital Calicut on 30.5.2007. The Opposite Party has not produced any document in support of their contention that the claimant had pre-existing disease apart from the claim application produced by the Complainant. In version the 2nd Opposite Party also avered that the investigators were appointed to get the <br /> details of the pre-existing disease of the claimant. The 1st and 2nd Opposite Parties have not produced any documents in support of their contention. The burden lies on the Opposite Party to bring forth in evidence that the claimant had pre-existing disease even at the time of her inception to the policy. The answer to the question No.6 in the application form in the claim cannot be treated as a parameter to repudiate the claim. The insurer cannot disown the liability in the ground of exception and not to be invoked unless there was some positive evidence of suppression of disease it is held by the Hon'ble National Consumer Disputes Redressal Commission in Praveen Dhamani V/S Oriental Insurance Company (2006(4) CPJ 189). From the above inferences the point No.1 is found in favour of the Complainant. The repudiation of the claim to the Complainant is a deficiency in service.<br /> <br /> 7. Point No.2:- The Complainant produced the patient bill issued by Malabar Institute of Medical Science Limited. Ext.A2 series is the bill issued to the Shelin Varghese the amount in the bill is Rs.11,869/-. The Complainant spent Rs.13,604/- in total towards the treatment charges and purchase of medicines. The claim of the Complainant Rs.5,000/- towards the other expenses in connection with the treatment is not supported by any evidence. Any how the Complainant's daughter had been undergoing treatment in Calicut and admitted in MIMS Hospital for 3 days. 1st Opposite Party acted as an agency in the middle for the insurance of their members with the 2nd Opposite party. The 2nd Opposite Party has to give the Complainant the amount spent for the treatment of the Complainant's daughter along with cost and compensation. The 1st Opposite Party is absolved from the liability.<br /> <br /> In the result, the complaint is partly allowed. The 2nd Opposite Party is directed to give Rs. 13,604/- (Rupees Thirteen thousand Six hundred and four only) along with cost<br /> Rs. 2,000/- (Rupees Two thousand only) to the complaint. The 2nd Opposite Party is directed to give the amount to the Complainant within one month from the date of this order.<br /> <br /> <br /> Pronounced in open Forum on this the 28th day of July 2008.<br /> <br /> <br /> PRESIDENT: Sd/-<br /> <br /> <br /> MEMBER-I : Sd/-<br /> <br /> <br /> MEMBER-II: Sd/-<br /> <br /> <br /> <br /> APPENDIX<br /> <br /> Witnesses for the Complainant:<br /> <br /> PW1. Vaghese.K.K. Complainant.<br /> <br /> Witnesses for the Opposite Parties:<br /> <br /> Nil.<br /> <br /> Exhibits for the Complainant:<br /> <br /> A1. Policy Certificate. <br /> <br /> A2.series Photo copy of the medical bills.<br /> (8 numbers)<br /> <br /> A3. Photo copy of the Discharge summary.<br /> A4. Copy of the Lawyer Notice. dt:14.7.2007.<br /> A5 series. Postal Receipts. dt:17.7.2007<br /> A6. Acknowledgment Card. <br /> A7 Returned Lawyer notice. <br /> A8. Reply Notice. dt:14.8.2007.<br /> A9. Copy of the Jan Arogya Bhima Policy Claim Form.<br /> A10. Copy of the Letter.<br /> A11. Postal Receipt.<br /> A12. Acknowledgment Card. <br /> A13. Notice. <br /> A14. Copy of the Letter. dt:27.11.2007.<br /> A15. Certificate. dt:30.11.2007.<br /> A16. Copy of the Medical Report to be accompanied <br /> by usual Claim from Under Hospitalization/<br /> Domiciliary Hospitalization Benefit Policy.<br /> <br /> Exhibits for the Opposite Parties:<br /> <br /> B1. Copy of the Jan Arogya Bhima Policy Claim Form.<br /> <br /> <br /> <br /> Sd/-<br /> <br /> PRESIDENT, CDRF, WAYANAD.<br /> <br /> <br /> //By Order//<br /> <br /> <br /> SENIOR SUPERINTENDENT<br /> CDRF, WAYANAD.