ORDER<br /> <br /> <br /> By Sri.K.Gheevarghese, President: <br /> <br /> The complaint filed under section 12 of the Consumer Protection Act.<br /> <br /> The gist of the complaint is as follows:<br /> <br /> The Complainant is an insurance policy holder of medi claim. The policy offers the benefits to the insured for the medical expences including rent , purchase of medi claim and the treatment charges would be given to the insured. The Complainant become the policy holder of the medi claim remitting Rs.664/- on 21.7.2006. The terms of the insurance further stipulates that the insured has to undergo treatment as inpatient atleast for a day. The Complainant during<br /> (Contd.....2)<br /> -2-<br /> the period of policy on 7.9.2006 was admitted in Fathima Hospital, Kozhikode and discharged from there on 8.9.2006. The medical expence for the treatment and other charges paid by the Complainant is the 9,274/-. In order to get the benefit of the claim the Complainant had given a claim application to the 2nd Opposite party. On accepting the application the 2nd Opposite party didn't respond to it either by way of rejecting or denying the claim on 2.3.2007 the Complainant send the lawyer notice. As a reply, the Opposite party stated that the investigation was going on. The Opposite parties are bound to give the claim benefits to the Complainant. Opposite parties may be directed to give the Complainant Rs. 9,274. The expences incurred for medical treatment notice expence Rs. 300/- and other along with cost and compensation for which Rs. 10,000/- is to be paid by the Opposite party.<br /> <br /> The Opposite party's were issued notice and Ist Opposite party filed version on their appearance. The 2nd Opposite party is declared exparte. The medi claim policy issued to the Complainant is admitted by the Ist Opposite party . The treatment covers from 22.7.2006 on wards. The hospitalisation of the Complainant was in September 2006. The history of the <br /> illness explains that Complainant is having narrowing valves which is less than 50% and it suffered from 22.8.206, one month after inception of the policy by the insured. The pannel of expert doctors of the 2nd Opposite party are of the view that the illness of the patient would have been in continuity of the disease before the inception to the insurance. The policy is not repudiated by the Opposite party at this juncture. It is premature to arrive at a decision. The Complainant is the filed with ulterior motives. There is no deficiency in service on the part of the Opposite party. The Complainant is to be dismissed with cost to the Opposite party.<br /> (Contd.......3)<br /> <br /> <br /> -3-<br /> The points in consideration are:<br /> 1. Is there any deficiency in service on the part of the Opposite party.<br /> 2. Relief and cost.<br /> Point No.1<br /> The Complainant filed proof affidavit. The notice published by the Opposite party is the Ext.A1. The stipulation of the notice contain that in order to get the benefit of the scheme the insured to be admitted in a hospital atleast for a day (24 hours) in 15 beded registered hospital. Ext. A2 is the policy to show that the Complainant is a policy holder. Ext. A3 series (3 in numbers) are the claim form and receipts. The Complainant was admitted in Fathima Hospital Kozhikode on 7.9.2006 and discharged on 8.9.2006. As per the Ext. A5 the admission for treatment was for the cart. Ext. A4, A5 and A6 are the reports on discharge summery and angiography. The medical treatment expences of the Complainant is Rs.9,274/- according to Ext. A7 series. The Opposite party was informed in time for the issuance of the claim . The claim was neither denied nor considered positively. The Opposite party has not produced any documents to substantiate the contention that the Complainant has any disease at the time of<br /> inception to policy for which he has undergone treatment. The claim kept in abeyance with the concept that it is premature at that stage is against reason and justice. The Opposite party's in action to the request of the complainant is a deficiency in service. The Point No.1 is found in favour of the Complainant.<br /> <br /> Point No.2<br /> The 2nd Opposite party is only a promoter of the claim the policy is insured by the Ist Opposite party. The relief is to be paid by the Ist Opposite party to the Complainant. The<br /> (Contd......4)<br /> <br /> -4-<br /> Complainant has spent Rs. 9,247 for the treatment. Medical bills of Ext. A7 shows the expence. Claim of the Complainant was not settled for a period of one year and as a result the Complainant had to be compensated. The Opposite party has to give the Complainant the benefit of the scheme and towards the compensation and cost Rs. 1000/- also to be paid. <br /> <br /> In the result the Ist Opposite party is directed to give the Complainant Rs. 9,274/- (Rupees Nine thousand two hundred and seventy four only). The amount which the Complainant spend medical treatment along with the compensation of Rs. 1,000/-(Rupees one thousand only). The Opposite party is also directed to give Rs. 1,000/- (Rupees one thousand only) towards the cost to the Complainant. In case of any failure on the part of the Opposite party. The Complainant can execute this order as per the provisions of law.<br /> <br /> Pronounced in open forum on this the 23rd day of February 2008.<br /> PRESIDENT: Sd/-<br /> MEMBER: Sd/-<br /> /True copy/<br /> PRESIDENT, CDRF WAYANAD.<br /> APPENDIX<br /> Witnesses for the Complainant:<br /> PW1 Ramakrishnan Peon, Govt.School Munderi.<br /> Witnesses for the Opposite party:<br /> Nil<br /> <br /> (Contd.....5)<br /> <br /> -5-<br /> Exhibits for the Complainant:<br /> A1 Notice published by Opposite party.<br /> A2 Individual Medi claim policy<br /> A3 series (3 numbers) Medi claim insurance policy<br /> A4 Medical report<br /> A5 Discharge summery<br /> A6 Coronary Angiography report<br /> A7 series Inpatient bill<br /> A8 Notice <br /> A9 Reply of Notice<br /> <br /> Exhibits for the Opposite parties<br /> <br /> Nil<br /> PRESIDENT, CDRF WAYANAD.