23/09/2014- The reasons for delay in disposal of this appeal can be seen from the order sheet.

1.        Heard, Mr. Alok Lal, learned Counsel appearing for the appellant on the point of limitation.

     On being satisfied with the grounds, the delay of about two months is condoned. 

2.        The notice on Respondents was accepted as valid on 7.9.12.  Thereafter inspite of several opportunities, nobody appeared on behalf of the Respondents. Accordingly this case was fixed for ex parte hearing. 

3.        The Complainant/Respondent No.1 filed this complaint case alleging that he took joint Medi-claim policy for him and his family.   At the time of taking policy his son Akash Verma had no pre-existing disease and he was examined by the Doctor of the appellant/Insurance Company.  His son had severe neck pain on 05.03.2009  and was advised surgery which was done at AMARI Hospital, Kolkatta.  Rs. 2,97,733.00 was spent in hospitalization and surgery.  He made an Insurance claim but it was repudiated on the ground of pre-existing disease.

4.        According to the Insurance Co. the insured had pre-existing disease which was chronic in nature and which position is clear from the medical papers.  The medi-claim was taken with some ulterior motive and was rightly repudiated. 

5.        Learned Lower Forum inter alia held that the claim has been wrongly repudiated and there is nothing to support that the insured had pre-exiting disease.  It directed O.P. No. 3 / Respondent No. 2 to make payment of Rs. 291,373.00 on its behalf and on behalf of the appellant/insurance company with compensation for harassment i.e.  Rs. 20,000.00 and litigation cost of Rs. 5,000.00.

6.        Mr. Alok Lal submitted as follows:

Mr. Akash Verma was major but neither the complaint was filed by him nor he presented himself for evidence.  The said medi-claim policy was taken by the complainant on 01.02.2009 and it is strange that just on the expiry of 30 days exclusion period in terms of clause 4.2 of the policy, the complainant alleged that Akash Verma developed severe neck pain, and was advised surgery;  accordingly surgery was done;  and he remained in hospital from 06.03.2009 to 12.03.2009.  From the medical opinion sheet of respondent No. 2 it will appear that degenerative spondylitis is a chronic condition as per MRI and therefore, the insured had pre-existing disease.  Mr. Lal therefore, submitted that the claim was rightly repudiated.  He also submitted that the complainant availed another parallel remedy for moving the International Consumer Rights Protection Council, and therefore this complaint is not maintainable. 

7.        There is no bar for one of the policy holder to peruse the case on behalf of his family member.  It is true that degeneration causes Spondylosis during the course of time, as indicated in medical opinion sheet of R-2 , but in this case, from the treatment Summary of AMRI Hospital, it appears that it was a case of Degenerative Spondylosis with dise prolapse; and there was sudden onset of neck pain on 03.03.2009, with restriction in neck movement. 

            That it appears to be a case of sudden onset of neck pain with neck restriction, for which immediate surgery was done.  The receipt of the Hospital, has been said to be genuine by learned Lower Forum.  

            Therefore, in our opinion the repudiation of claim on the ground of pre-existing disease is wrong.  It may be a coincidence that the sudden pain with restriction in neck movement happened a few days after the expiry of the 30 days exclusion period. 

            Further, the remedy before this Forum is additional remedy, which cannot be denied on the ground that the Complainant has also moved the International Consumer Rights Protection Council. 

            In the result, this appeal is dismissed.  

                       Issue free copy of this order to all concerned for information and needful.

                         Ranchi,

                        Dated:-23/09/2014