By Smt. Padmini Sudheesh, President The averments in the complaint are as follows: The first petitioner had taken a mediclaim insurance policy bearing No.100606/48/037/012973/2000 dated 2.5.2000 from the respondent insurance company. The policy has got validity for the period from 28.4.2000 to 27.4.2001. Apart from the first petitioner as insured, the policy taken in respect of her family members too. The overall limit in respect of the petitioners and the first petitioners husband was Rs.50,000/- each and for both the children had Rs.30,000/- each. On expiry of this policy the first petitioner took another mediclaim policy bearing No.100606/48/037/015322002 dated 8.5.2001 for the period from 8.5.2001 to 7.5.2002 to cover the above named persons for the same insurance coverage as specified in the prior policy. This second policy is in continuation of the previous policy. When this policy expired the first petitioner took another mediclaim policy bearing No.100600/48/00247 dated 21.5.02 having validity for the period from 8.5.2002 to 7.5.03. This is also in continuation of earlier policies. On expiry of third policy, the first petitioner took another mediclaim policy bearing No.100600/48/03/00097 dated 6.5.03 for the period from 8.5.03 to 7.5.04 to cover the above named persons for the same insurance coverage as specified in the prior policies. The fourth policy is also in continuation of the earlier polices. The fourth policy got continued at the time of filing this O.P. During the coverage of policy the second petitioner had undergone hospitalization and treatments and for the expenses incurred, the first petitioner had preferred the claim to the respondent company but was rejected. On 3.6.02 the second petitioner had minor ailment in her stomach and she immediately consulted by a Doctor named Dr. T.I. Radhakrishnan who suggested her to take certain medicines prescribed by him and assured her that the ailment would be cured on taking the medicines. Though there was an initial relax to her illness after taking medicines, it was suddenly aggravated and the pain became severe on 3.7.02 and immediately consulted the above named doctor and he referred the second petitioner for scanning. On 10.7.02 she was taken to the Mother Hospital, Pullazhi, Thrissur and the doctor who attended her advised that the illness from which she had suffered was Incisional Hernia and commenced treatment. In spite of medical treatment, there was no sign of improvement in her ailment and instead it deteriorated further. On 26.8.02 the second petitioner was admitted in the hospital as an inpatient as I.P.109085 for better pathological treatment. During the course of her treatment as inpatient, the doctor suggested immediate operation since her illness would not be cured on mere medicines. On 30.8.02 the second petitioner had undergone operation. After completely getting herself cured she was discharged on 9.9.02. The total medical expenses incurred by her during the period (from 10.7.02 to 9.9.02) come to Rs.39,135-20. On the basis of the policy the first petitioner submitted claim application together with all relevant documents, but was rejected by the company stating that pre-existing diseases are excluded from the scope of the policy. Hence this complaint. 2. The averments in the counter are as follows. The respondent denies every averments in the petition except to the extent that they are specifically admitted hereunder. The complainant stated that they were taken mediclaim policy from 2000 onwards and the complainant were already claimed the medical expenses prior to this claim. That claims were settled by the respondent company. The payments were accepted by the complainants and they enjoyed the amounts as per the mediclaim policy. The insurance coverage applies to the 05 years and these people prior to this claim the complainant had already availed the medical expenses and hospital bills from the respondent insurance company. The company had already accepted the expenses and they allowed. But the Doctor advised that the 2nd complainant suffered from incisional hernia and advised for surgery and she had undergone operation. As per the mediclaim policy condition No.4.1, pre-existing diseases are excluded from the scope of the policy. As per the policy conditions, some diseases are excluded from the medical reimbursement. That is clearly stated in the policy conditions. The repudiation of the claim is not the way to unlawful monetary gain to the insurance company. So the respondent companys repudiation of the first petitioners claim not amounts to unfair trade practice and deficiency in service. There is no willful delay for the return of the medical bills, prescriptions and hospital records. Hence dismiss the complaint. 3. The points for consideration are: (1) Is there any deficiency in service? (2) If so reliefs and costs. 4. The evidence consists of Exts. P1 to P11 and R1. No other evidence. 5. Point No.1: There is a definite case by the petitioners that they are entitled for the expenses incurred for the medical treatment of second petitioner. To prove the case they have produced eleven documents and marked as Exts. P1 to P11. In the petition it is stated that the first policy had taken on 2.5.00 and valid for the period from 28.4.00 to 27.4.01. The insurance coverage has got to all the family members also. There are four policies described in continuation of the earlier policies. The respondent company has filed counter in which there is no denial of continuation of policies. Since all the policies are continuing, the conditions of all policies are applicable. During the existence of Ext. P3 policy the second petitioner has undergone treatment for Incisional Hernia from 3.6.02 and undergone operation on 30.8.02 and discharged on 9.9.02. This was during the coverage of Ext. P3 policy. According to the petitioner total expenses incurred by her during the period come to Rs.35,135/-. Since the claim limit is up to Rs.50,000/- she is entitled to get this amount. After the treatment the first petitioner applied for the medical insurance claim to the respondent company, but it was rejected. From the counter it is stated that prior to this claim these complainants had already availed the medical expenses from the respondent company. This claim was rejected by stating that as per the mediclaim policy condition No.41 pre-existing diseases are excluded from the scope of the policy. That is clearly stated in the policy conditions. So the repudiation does not amount to unfair trade practice and deficiency in service. But this view of the company cannot be accepted. Because the policy starts from 28.4.00 and for the said disease she had consulted the doctor only on 3.6.02. As per Ext. P6 claim form the first detection of the illness is 10.7.02 and also the medical report attached to this document shows that the person would have been suffering from this illness is two years. The treated doctor Dr. Dileepkumar certified that the history of the illness is two years and this also within the period of first policy. There is no medical evidence or other evidence to show that this person has undergone treatment for this disease before that. It is true that the disease is not occurring all of a sudden, but in the absence of proof of medical consultation the defence of pre-existence does not prevail. Knowledge of the pre-existence is also not proved. There is no evidence to establish the contention of respondent company. So the service deficiency of respondent is proved in rejecting a genuine claim. 6. Point No.2: The next point is the relief available to the complainants. Only because of the service deficiency this claim has repudiated. There is nothing to support the case of respondent. The medical expenses incurred to the second petitioner is Rs.39,135/-. The claim limit is Rs.50,000/-. Hence the company is liable to provide this amount. The bills are produced is marked as Ext. P11 series. There is nothing to disbelieve the case of complainants. So the complainants are entitled for this amount. For the service deficiency the complainants are also entitled for Rs.2500/- as compensation. 7. In the result, complaint is allowed and the respondent Company is directed to pay Rs.39,135/- (Rupees thirty nine thousand one hundred and thirty five only) to the petitioners without interest and also directed to pay Rs.2500/- (Rupees two thousand and five hundred only) as compensation and Rs.500/- (Rupees five hundred only) towards costs. Comply the order within one month. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 18th day of September 2008.
