By Sri. P. Raveendran, Member:

The Complainant is Member of Mananthavady Ksheera Sahakarana Sangam as per M No.90. The Complainant joined in Medi claim Insurance Policy of Opposite Party No.1 for the benefit of the above sangam members which is known as Ksheera Karshaka Arogya Suraksha Padhathi by paying Rs.214/- as premium. The Complainant joined in the scheme through Opposite Party No.2. The wife of the Complainant Mrs Merey @ Mary is also a beneficiary under the insurance scheme. While so Complainant's wife treated at MIMS Hospital Calicut for Aortic Dissection as inpatient from 18.10.2009 to 29.10.2009 and Complainant spent Rs.2,49,990/- for the treatment. Immediately after the treatment the complainant submitted treatment records to Opposite Party No.1 through Opposite Party No.2 and Opposite Party No.1 rejected the claim stating that on verification of discharge summary the disease is pre-existing even before joining the scheme. The doctor who treated the Complainant's wife certified that it is not a pre-existing dissection. Thus it is clear that the rejection of the insurance claim by Opposite Party No.1 is without any basis, is amounts of deficiency in service on the part of the Opposite Party No.1. As a result of the same huge loss and mental agony has been caused to the Complainant. Opposite Party No.2 is impleaded as a abundant caution to avoid plea of non jointer. Hence it is prayed to pass an order directing the Opposite Party No.1 to pay an amount of Rs.2,49,990/- and Rs.50,000/- as compensation and cost of this litigation.

2. Opposite Parties No.1 and 2 appeared and filed their versions. In the version of 1^st Opposite Party admitted that the Complainant and his wife Smt.Mary were insured as per Ksheera Karshaka Arogya Sureksha Paddadi. The policy commenced from 01.07.2009 to 30.06.2010. Hospitalization claim was reported by the Complainant in respect of his wife Smt. K.M. Mary for the treatment Aortic Dissection. Type A moderate Regurgaion dyslipidema, taken at MIMS Kozhikode for the period from 18.10.2009 to 29.10.2009. As per the discharge summary the patient was admitted with acute onset of chest pain radiating to inferscapular are followed by one episode of syncope. And she had history of on going pain and is a dyslipidemic. As per exclusion clause No.4.1 the Opposite Party shall not liable to make any payment under the policy in respect of any expense what so ever incurred by any insured person in connection with or in respect of all disease which are pre-existing when the cover incepts for the first time. Since the disease reported being a pre-existing one the Opposite Party repudiated the claim. There is no deficiency of service on the part of this Opposite Party as alleged in the complaint. Without prejudice to the above contention Opposite Party submitted that as per the scheme maximum amount payable in eligible case for one disease is Rs.20,000/-. If the claim of the Complainant is admissible the liability will be restricted to sum of Rs.2,800/- towards room rent, Rs.350/- towards doctors fee and Rs.5,000/- towards medicine and others ie Rs.8,150/- in total. Hence the Forum may dismiss this complaint with cost.

3. The version of 2^nd Opposite Party is as follows. 2^nd Opposite Party contented that the medi-claim insurnace scheme is not owned or introduced by 2^nd Opposite Party. It is a project introduced by MRCMPU Calicut along with 1^st Opposite Party for the benefit of the members of the primary Ksheera Sangam which was chanalized through 2^nd Opposite Party. The premium collected by 2^nd Opposite Party handed over to MRCMPU and they paid the amount to 1^st Opposite Party when the Complainant submitted the treatment records of his wife, 2^nd Opposite party immediately forwarded the same to 1^st Opposite Party. There was no deficiency of service on the part of the 2^nd Opposite Party. Hence it is prayed that this Forum may be pleased to dismiss the complaint with cost.

4. On considering the complaint and versions the following points are to be considered.

1. Whether there is any deficiency of service on the part of the Opposite Parties.

2. Relief and cost.

5. Point No.1:- To prove Complainant's case he has produced his proof affidavit and Exts.A1 and A2 documents. In the proof affidavit he has stated as stated in the complaint Ext.A1 is the repudiation letter given by the 1^st Opposite Party to the Complainant. Ext.A2 is the certificate issued by Dr. Anupkrishnan.V, MIMS, Calicut. 1^st Opposite Party filed his Chief affidavit and Ext.B1 to B4 were marked. In the Chief affidavit he stated as stated in the version. Ext.B1 is the copy of Ksheera Karshaka Arogya Suraksha Paddathi application form. Ext.B2 is the true copy of Universal Health Insurance Policy Scheme with Ksheera Karshaka Arogya Suraksha Paddathi. Ext.B3 is the claim form of Ksheera Karshaka Arogya Insurance submitted by the complainant to the 1^st Opposite Party. Ext.B4 is the Medical report issued by Dr. Anupkrishnan V, MIMS Calicut. On going through Ext.A1 and Ext.B4 produced by both sides it is clear that the decease developed suddenly ie from 18^th October 2009. But the policy is from 01.07.2009 to 30.06.2010. That means the decease developed after joining in the policy. Hence the contention of Opposite Party ie the disease is existing even before joining the scheme is not correct and it amounts to deficiency of service on the part of 1^st Opposite Party. No deficiency of service on the part of 2^nd Opposite Party point No.1 decided accordingly.

6. Point No.2 :- Ext.B2 is the Ksheera Karshaka Arogya Suraksha Paddathi. Details of the Paddathi is mentioned in it. According to it the Ksheera Karshakan is entitled to maximum of Rs.5,000/- towards Doctors fee, Nursing fee etc. On going through Ext.X1 it is revealed that the Complainant has spent more than Rs.5,000/- towards that head. So he is entitle to get that amount from 1^st Opposite Party. Likewise the Complainant is entitled to get maximum of Rs.5,000/- towards Medicines, tests and artificial organs. In this case also it is clear that the Complainant has paid more than Rs.5,000/- towards that head. So the Complainant is entitle to get that amount from 1^st Opposite Party. He is also entitle to get Rs.1,500/- towards ICU charge and Rs.400/- towards bed charges. So the Complainant is entitled to get Rs.11,900/- from the 1^st Opposite party. He is also entitle to get 10% interest for the said amount from date of filing of the complaint till the payment is made. He is also entitled to get Rs.1,000/- as cost of this litigation.

In the result, the complaint is partly allowed and 1^st Opposite party is directed to pay Rs.11,900/- (Rupees Eleven thousand Nine hundred only) to the Complainant with 10% interest for the above amount from the date of filing the complaint till the payment is made. He is also directed to pay Rs.1,000/- (Rupees One thousand only) as cost of this litigation.

Pronounced in open Forum on this the day of 29^th September 2010.

PRESIDENT: Sd/-

MEMBER : Sd/-

MEMBER : Sd/-

A P P E N D I X

Witness for the Complainant:

PW1. Mathai. Complainant.

Witness for the Opposite Parties:

OPW1 K. Pradeep. Asst. Manager, Oriental Insurance Co. , Thrissur.

Exhibits for the Complainant:

A1. Copy of Letter. dt:28.12.2009.

A2. Certificate issued by Dr. Anup Krishnan V.

Exhibits for the Opposite Parties:

B1 Copy of Application form.

B2. Universal health Insurance Policy Schedule. dt:20.04.2010.

B3. Ksheera Arogya Insurance Claim Form.

B4. Medical Report.

X1 series Discharge Summary.