KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSIONN VAZHUTHACADU, THIRUVANANTHAPURAM APPEAL NO.78/2003 JUDGMENT DATED: 10.12.2007 Appeal filed against the order passed by the CDRF, Ernakulam in OP.881/2001 PRESENT SHRI.M.V.VISWANATHAN : JUDICIAL MEMBER SHRI.S.CHANDRAMOHAN NAIR : MEMBER The Divisional Manager, National Insurance Co.Ltd., : APPELLANT Thripunithura, Ernakulam. (By Adv. Saji Issac.K.J.) Vs K.K.Shaji, Kulleri House, Nadakkavu.P.O., : RESPONDENT Udayamperoor, Thripunithura. (By Adv.Babu Cherukara) JUDGMENT SHRI.M.V.VISWANATHAN : JUDICIAL MEMBER This appeal is directed against the order dated 30th October 2002 of CDRF, Ernakulam in OP.881/01. The complaint in said OP.881/01 was filed claiming the insurance claim with respect to mediclaim insurance policy taken by the complainant from the opposite party/Insurance Company. The opposite party repudiated the claim on the ground that the complainant was admitted in the hospital for rheumatic heart disease with in one month and so the claim under the policy is unsustainable. The lower Forum on an appreciation of the evidence adduced from either side came to the conclusion that there was deficiency in service on the part of opposite party/Insurance Company in repudiating the insurance claim. Thereby the opposite party is directed to entertain the claim preferred by the complainant. The complainant is also directed to pay cost of Rs.250/-. Aggrieved by the said order the present appeal is preferred. 2. We heard the counsel for the appellant and the respondent. The learned counsel for the appellant Insurance Company argued for the position that the respondent/complainant contacted rheumatic heart disease within 30 days of the policy. He also relied on the recitals in Ext.P1 mediclaim policy and also Ext.A3 and A4 documents. On the otherhand, the learned counsel for respondent/complainant supported the findings and conclusions of the lower Forum and requested for dismissal of the present appeal. 3. The points that arise for consideration are:- 1) Is there occurred any deficiency in service on the part of the appellant/opposite party in repudiating the claim under the mediclaim Insurance policy? 2) Is there any unsustainable ground to interfere with the impugned order passed by the lower Forum? 4. Points 1 and 2:- Admittedly the respondent/Complainant is a mediclaim insurance policy holder and that policy was effective from 9.5.01 to 8.5.02. Admittedly respondent/complainant was admitted in the hospital on 8.7.01 and discharged on 10.7.01. He preferred the claim for Rs.31,520.48 from the opposite party as the amount spent in connection with his treatment. The appellant/opposite party relied on Ext.A4 mediclaim certificate issued by Cardiologist attached to Amrita Institute of Medical Science. It is stated in A4 medical certificate that the complainant as the patient had the illness for the probable duration of one month. It is on the basis the said recital in A4 the appellant/Insurance Company contended that the respondent/ complainant had contacted the disease with in one month from the date of the policy. It is to be noted that the A4 certificate was issued on 10.7.01. If that be so, the one month time will commence on 11.6.01. If the date of admission is taken as the relevant date for computing the period of one month, then also the period of one month from the date of the policy would completes by 8.6.01. Then it can be concluded that the respondent/ complainant contacted the disease after the lapse of 30 days. It is to be noted that the A4 certificate was issued on the date of discharge ie 10.7.01. So, the one month time is only the probable duration of illness and it can be taken as the date of discharge. If that be so, the date of commencement of the illness can be taken as 11.6.01. So, at any rate it can be concluded that the respondent/complainant contacted the disease after the lapse of 30 days from the date of commencement of the Insurance Policy. The lower Forum is fully justified in directing the appellant/opposite party to entertain the insurance claim putforward by the respondent/complainant. 4. The other case of the appellant/opposite party is that the respondent/complainant had the rheumatic heart disease even prior to the taking of the policy on 9.5.01. But there is nothing on record to show that the respondent/complainant had undergone treatment for rheumatic heart disease prior to 9.5.2001. The mere fact that in Ext.A3 discharge summary it is stated that the complainant is a known case of rheumatic heart disease cannot be taken as a ground to hold that the respondent/complainant was aware of his disease even at the time of taking the policy. There is no material available on record to support Ext.A3. The appellant/opposite party could not adduce any evidence to show that the complainant was having any such disease prior to taking of the policy on 9.5.01. Thus, in all respects it can be concluded that the respondent/complainant is entitled to get the mediclaim under the mediclaim insurance policy which was effective from 9.5.01 to 8.5.02. We do not find any legally sustainable ground to interfere with the impugned order passed by the lower forum. So, the present appeal is liable to be dismissed. Hence we do so. The points are answered accordingly. In the result appeal is dismissed. Impugned order passed by the lower Forum is confirmed. There will be no order as to costs. SHRI.M.V.VISWANATHAN : JUDICIAL MEMBER SHRI.S.CHANDRAMOHAN NAIR : MEMBER | 
