BY SRI.K. VIJAYAKUMARAN, PRESIDENT This is a complaint for realization of insurance amount. The averments in the complaint can be briefly summarized as follows: The complainant is a retired L.P. School Headmistress. The complainant has taken a Insurance policy from the 2nd opp.party through one Mr. Rav eendran Pillai who is an agent of the opp.parties. As per the terms and conditions of the policy if the complainant contracts any decease or illness which required hospitalization the expenses as impatient will be paid by the opp.party subject a the maximum of Rs.15,000/- While the policy was in force the complainant sustained headache and she approached M/s. Upasana Hospital, Kollam where she was admitted on 9.3.2004 and was treated as an inpatient and she was discharged on 11.3.2004. Again she was admitted in the same hospital and for better treatment she was referred to Amrita Institute of Medical Science, Cochi . In the Amritha Institute of Medical Science she was admitted on 16.3.2004 and after examination and investigation she was diagnosed as Mild Falicine Meningioma for which she underwent a surgery known as Left Parietal f Parasagiffal Craniotamy and Simpson’s grade II Excision on 19.3.2004 and she was discharged on 26.3.2004. In the above hospital lthe complainant incurred an expenditure of Rs.43,242/- towards hospital charges. When the complainant filed a claim under the policy the same was repudiated by the opp.parties on the grounds that the disease for which she had undergone treatment was pre-existing. Hence the complaint. The opp.party filed version contending, interalis, that the complainant is not maintainable either in law or on facts. This Forum has no territorial jurisdiction to entertain this complaint. The complainant has approached the Forum with unclean hands . The definition complaint, complainant, Consumer Dispute service as defined in section 2[1] of Consumer Protection Act do not cover the claim made out in the complaint. The opp.party had issued an insurance policy covering the complainant and her family members under Universal Health Insurance Scheme for a period from 26.12.2003to 25.12.2004. As per the coverage given under the policy the insured persons are eligible to get a medical reimbursement for hospitalization and treatment expenses to a maximum of Rs.15,000/- subject to the terms and conditions governing the policy. The opp.party has issued the Universal Health Insurance Policy to the complainant fully trusting the declaration given in the proposal form submitted by her which shall form the very basis of the insurance contract. The complainant has given incorrect answer or particulars for the questionnaires given in the proposal form. The complainant infact was suffering from the symptoms of Mid Falcine Meningioma about 1 year prior to the commencement of the policy as the medical history issued from Amritha Institute of Medical Science. The complainant was suffering from gradual onset of generalized headache, which was progressing over the past two months associated with inability on walking before her admission at Upasana Hospital on 9.3.2004. Apart from that the complainant had a further episode of blackout about one year back before her admission at Upasana Hospital for which she had undergone investigation. The above facts were honestly disclosed by the complainant to the doctor at Amrita Institute of Medical Science land Research Center . As per the medical history revealed by the complainant before the treated doctor it is evident that she was suffering from gradual onset of generalized headache before it was aggravated over the past two months prior to her treatment at Upasana Hospital. The complainant obtained the insurance policy commencing from 26.12.2003 only and she got admitted at Upasana Hospital, Kollam on 9.3.2004, . According to the admission made by the complainant herself before the treated doctor at AIMs, she was suffering from severe headache for a period at least from 9.1.2004 and prior to that she was suffering from generalized headache for a considerable period. So the complainant was suffering from the disease for which she had treated much prior to her joining in the insurance scheme and the said material facts has been deliberately suppressed by the complainant in the proposal form submitted by her before the opp.party. As per condition No.4[2] of the Universal Health Insurance Policy any disease contracted by the insured person during the first 30 days from the commencement date of the policy is excluded. As per exclusion clause the company shall not be liable to make any payment under the policy in respect of any expenses incurred by the insured person relating to the diseases which have been in existence at the time of proposing the insurance. Pre-existing means the complications arising from pre-existing disease will be considered part of that pre existing condition. In the instant case the complainant was fully aware of the fact that she was suffering from the diseases of neurological problems at the time of proposing for the insurance and as such the opp.party is not liable to make any payment to the complainant as per the specific exclusion clause in the policy. The opp.party has repudiated the claim of the complainant on genuine land valid ground . There is no deficiency in service on the part of the opp.parties. Hence the opp.party prays to dismiss the complaint. Points for consideration are:: 1. Whether the complainant is entitled to get Insurance amount? 2. Whether there is deficiency in service on the part of the opp.parties ? 3. Reliefs and costs For the complainant PW.1 is Examined. Ext.P1 to P9 are marked. For the opp.parties DW.1 is examined. Ext. D1 to D6 are marked. Points: As a matter of fact policy is admitted . The complainants case is that she was admitted in the Amritha Institute of Medical Sciences in connection with her illness and when she preferred the claim the same was repudiated as per Ext.P8 which is illegal. The opp.parties repudiated the claim on two grounds. Firstly on the ground that the complainant was suffering from pre existing disease. According to the opp.parties the complainant herself has stated in Ext.P9 to the doctor at the Amritha Institute of Medical Sciences and Research Centre that she had an episode of black out one year prior to that date but she has suppressed the same while giving Ext.D2. Proposal Form which is a deliberate suppression of material fact which would vitiate the policy. It is to be pointed out that on investigation nothing wrong was noticed and no treatment has been taken by the complainant for the same . If black out was in connection with any disease naturally some treatment or medication would have been necessary. So the omission to mention black out in Ext.D2 proposal Form in our view has no significance and it cannot be said that there is any material suppression. Apart from that Note [b] of exclusion clause 4.2 of Ext. D1 says that exclusion 4-1 and 4-2 shall not apply if the insured has not taken any consultation treatment or mediccation The second ground of repudiation is that the claim is inadmissible as it is hit by exclusion clause 4.2 of the policy. Exclusion clause 4.2 says that any disease contracted by the insured during the 1st 30 days from the commencement date of policy the company shall not be liable to make any payment under the policy. It is argued by the learned counsel for the opp.parties that in Ext.P9 the complaint herself has stated to the doctor that she was having generalized headache for 2 months with inability of walking prior to her admission in the AIMSRC. On 16.3.2004. Prior to going to AIMSRC the complainant had gone to Upasana Hospital, Kollam on 9.3.2004 and was discharged on 11.3.2004 for the headache and was again readmitted on 15.3.2004 and thereafter she was referred to Amritha Institute of Medical Scie4nce and Research Centre. So according to the learned counsel for the opp.parties the on set of headache is at least from 9.1.2004 and the policy has been commenced from 26.12.2003 which means that the insured has contracted the disease within 15 days of the commencement of policy and as such the claim is hit by exclusion clause 4.2 As pointed out earlier the complainant herself has stated to the doctor that she was suffering from gradual onset of generalized headache which was progressing over the past 2 months associated with inability to walk PW.1 has no case that the insured has stated so by any mistake. Not even a suggestion was made to PW.1 that it is due to any inadvertent mistake. Therefore we are of the view that so we fee that we shall not be justified in interfering with the repudiation. Point found accordingly. In the result the complaint fails and the same is dismissed. No costs. Dated this the 29th day of April, 2009. . I n d e x List of witnesses for the complainant PW.1. – Sethunath List of documents for the complainant P1. – Policy certificate P2. – Discharged card from Upasana Hospital P3. – Discharged card dt. 26.3.2004 from AIMS P4. – Bill dt. 26.3.2004 from Amrita Hospital P5. – Advocate Notice P6. – Postal receipt P7. – Acknowledgement card P8. – Reply notice P9. – Discharge summary from AIMS List of witnesses for the opp.parties DW.1. – G. Leela List of documents for the opp.parties D1. – Insurance policy and Policy condition D2. – Subjected to admissibility D3. – Discharge summary D4. – Discharge bill D5. –Repudiation letter D6. – Reply notice. | 
