By Smt. Padmini Sudheesh, President: Petitioners case is as follows: 1. Petitioner is an insurance policy holder of the first respondent and he had become the policyholder only because of a subscriber of the second respondent. He has submitted a claim form to the first respondent for the treatment availed to him. He has availed treatment for ulcer and headache. The amount claimed was below Rs.3000/-. But the claim was repudiated by the company. Later lawyer notice sent, but no remedy. Hence this petition. 2. The first respondent filed a version as follows: This respondent admitted that they have issued a Mediclaim Group Insurance in favour of second respondent for its employees/members. This respondent has received a claim from the first respondent. The allegation that he has availed treatment for ulcer is not correct. This respondent has availed all medical bills and other document submitted by the claimant. He was admitted in the hospital with a complaint of burning lower half of abdomen. The patient has noted palpitation, afraid, a feeling of panic. The observations of the treated doctor show that the claim is inadmissible. As per medi claim Clause 4(10), he is not entitled for the claim. This is intimated by a letter dated 13.2.04. Hence dismiss the petition. 3. Second respondent is declared as exparte. 4. The points arise for consideration are: - (1) Whether the petitioner is entitled to get the claim amount? (2) Reliefs and costs. 5. The evidence consists of Exts. P1 and R1 to R6. 6. Point No.1: According to the petitioner, he has submitted a claim form to the first respondent for the treatment availed to him. The treatment was within the policy period. The claim was repudiated by the Company stating that diagnosis is exempted from the purview of the policy. He has claimed an amount below Rs.3000/-. 7. As per the policy conditions, Clause 4.10 charges incurred at Hospital or Nursing Home primarily for Diagnostic etc. are excluded. According to the company diagnosis is excluded. In this case the petitioner has undergone treatment for the disease suffered. As per Ext. R5, the doctor had reported that he is on treatment. The respondent company has no case that this kind of diseases is excluded from the policy benefits. They had contended only on the basis of Clause 4.10 of the Policy. Here the rejection of the claim is on unreasonable ground. So he is entitled for the policy benefits. 8. Point No.2: The evidence showing the expenses is not produced. But going through the claim form, which is marked as Ext. R2, it was stated that Rs.2599/- is the expenses. The first respondent also not disputed that amount. They are disputing only the quantum of compensation asked by the petitioner. 9. In the result, the petition is allowed and the first respondent is directed to pay to the petitioner Rs.2599/- (Rupees two thousand five hundred and ninety nine only) as the policy benefits; Rs.1000/- (Rupees one thousand only) as compensation and Rs.500/- (Rupees five hundred only) towards costs. Time for payment one month. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 30th day of May 2008.
