By Smt. Saji Mathew, Member<br /> <br /> The gist of the case is as follows:<br /> <br /> The 1st complainant has taken a mediclaim insurance policy as per policy No.101601//48/02/01005 from the opposite party paying a premium of Rs.671/-. The policy coverage period was from 11.2.03 to 10.2.2004. As per the policy condition, the opposite party has to pay all the medical expenses if the spouse of the policy holder is hospitalized and treated during the coverage period. On 29.11.2003, the 1st complainant's wife Rosamma was admitted in Victory hospital, S. Bathery, for treatment of hypertension and back pain. The medical expense was Rs.6,500/-. The 1st complainant claimed for the reimbursement of this amount from the opposite party. But the opposite party has repudiated the claim without showing any reason. The complainant has renewed the policy as 101601/48/03/01048 for the period from 11.2.2004 to 10.2.2005. As per this policy also coverage was given to the complainant's wife, Rosamma. On 12.3.2004 Rosamma was hospitalised in Vinayaka Hospital, S Bathery for treatment and discharged on 20.3.2004. The expense for the treatment was Rs.6023. The complainant claimed this amount from the opposite party but no response. Then the 2nd complainant, son of 1st complainant has renewed the policy as per policy No. 101601/48/0401897 paying Rs.1,709/- . So as to cover his wife and child as well as his parents. The period if coverage was 11.2.05 to 10.2.2006. Rosamma was again hospitalised in Vinayaka hospital S. Bathery and Rs.2304 was spent. On the claim for this amount the opposite party has sanctioned only Rs.1443. The complainant has refused this amount and sent a lawyer notice to the opposite party. The opposite party has neither complied with the demands of the complainant nor replied to complainants notice. Hence, the complainant has filed this complaint seeking an order directing the opposite party to pay the 1st complainant Rs.12,523/- with 12% interest and to pay the 2nd complainant Rs.2304 as per the policy conditions.<br /> <br /> 2. The opposite party appeared and filed version. The opposite party just deny that the complainant is entitled for any relief. The opposite party has paid the amount which the complainant is legally entitled to get. So they seek an order dismissing the complaint. The complainant was examined as PW1. The complaint's wife was examined as PW2. Ext. A1 to Ext. A8 were marked on the side of the complainant. The opposite party was examined as OPW1. Ext. B1 and Ext. B2 were marked on the side of the opposite party.<br /> <br /> 3. The issues to be considered are as follows:<br /> <br /> 1) Whether there is any deficiency in service on the part of the opposite party.?<br /> 2) Whether the complain ant is entitled to get any relief.?<br /> <br /> 4. Point No.1: OPW1 admits the 3 mediclaim policies taken by the complainants. There is also no dispute regarding the period or range of the coverage. The opposite party does not deny the matter of 3 claims made under 3 policies. The complainants have filed a petition to call for documents regarding the 1st and second claim. Upon the order of the Forum to produce these documents, the opposite party filed affidavit stating that they could not trace it out. The opposite party has no case that the claims were not made. They do not even have a specific case in the version that the ailment of the beneficiary was pre existing before the policies. In the proof affidavit, opposite party vaguly state that the illness of Mrs. Rossamma was preexisting before 2007. the policy was taken in 2003 and coverage period is from 2003 to 2006 opposite party's proof affidavit lightly state that high blood pressure and back pain are normal ailments pertaining the body structure and age of Rosamma. In the cross examination of PW1 and PW2, opposite party mention the body weight, age and even menopasuse problems. It is very irresponsible and unfair on the part of the opposite party to issue policy and take premium and tease the policy holder when the claim is put forward. It is found that there is gross deficiency in service on the part of the opposite party.<br /> <br /> 5. Point No.2: There is no documents regarding the 1sr and 2nd claim made under policy No.101601/48/02/01005 and policy No.101601/48/03/01048 respectively. The opposite party do not specifically deny the amount of claime under the policies. Under the third policy No 1016012/48/04/01897 the opposite party has allowed 1443. The opposite <br /> party has stated in the proof affidavit that Rs.1443 was allowed on the basis of the document produced by the complainant. But that document were not produced before the forum for verification. So, the complaint is taken as genuine and true. The opposite party has to give the amount claimed by the complainant under the policy.<br /> <br /> Hence it is directed that the opposite party has to give Rs.12,523/-( Rupees twelve thousand five hundred and twenty three only) to the 1st complainant and Rs.2,364/-(Rupees two thousand three hundred and sixty four only) to the 2nd complainant within 30 days of this order. Interest on this amount at a rate of 10% should be given from the date of the complaint till payment. No order as t o the cost and compensation<br /> <br /> Pronounced in the open Forum on this the day of 19th August, 2008.<br /> PRESIDENT: Sd/-<br /> <br /> MEMBER – I : Sd/-<br /> <br /> MEMBER – II: Sd/-<br /> APPENDIX:<br /> Witness examined for complainant:<br /> PW1 Sunil George Agriculture<br /> PW2 Rosamma Housewife<br /> Witness examined for opposite party:<br /> OPW1 Pradeep Kumar Manager<br /> Exhibits marked for complainant;<br /> A1Policy scheduleA2 Policy receipt<br /> A3 Policy schedule<br /> A4 Details of treatment<br /> A5 Medical Bill Series<br /> A6 Discharge card<br /> A7 Settlement intimation voucher<br /> A8 Lawyer notice<br /> Exhibits marked for opposite parties:<br /> B1 Copy of claim form<br /> B2 Original policy