DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PALAKKAD

 Dated this the 18th day of August 2009.

 Present : Smt. H. Seena, President

: Smt. Preetha.G. Nair (Member)

: Smt. Bhanumathi.A.K. (Member)

C.C.No.101/2008

M.S. Ajithkumar

S/o. Surendran

Kalathil House

Kottekulam

Koranchira (P.O)

Kizhakkenchery

Alathur Taluk

Palakkad. - Complainant

(Adv. Jacob Mathew)

V/s

M/s. National Insurance Co Ltd

3^rd Floor

East Fort Complex

Fort Maidan

Palakkad – 678 013 - Opposite Party

(Adv.S.T. Suresh)

O R D E R

By Smt. Bhanumathi.A.K, Member

In short the complaint is as follows.

The complainant and his family members were covered by the Medi claim Insurance policy conducted by the opposite party. The policy was in effect from 10.05.2005 to 09.08.2006 and the original Policy Number was 570705/46/05/8500000542 and the policy was renewed on 10.08.2006 by paying an amount of Rs.1435/- as premium. The renewed Policy Number is 570705/48/06/8500000/455. It is a hospitalization and domiciliary hospitalization benefit policy. On 05.02.2007, during the policy covered period, the younger son of the complainant Master Adarsh M A had under gone an operation for PDA Coil closure in the Amrita Institute of Medical Sciences and Research Centre, Cochin and a total amount of Rs.35,000/- spent for the medical treatment. Since the family members of the complainant were insured with the opposite party in this medi claim policy, the opposite party is liable to disburse the policy amount to the complainant. Immediately after the

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treatment was completed , the complainant had submitted the entire records of treatment along with the medical bills for claiming for the insurance benefit. The opposite party refused to compensate the complainant and issued a letter dated 10.11.2007 rejecting the complainants claim. So the complaint approached the forum seeking an order directing the opposite party to pay an amount of Rs.35,000/- being the medical expenses together with 18% interest from the date of treatment till realization and cost of the proceedings.

Complaint was admitted. Opposite party filed version. The contention of the opposite party is that, Master Adarsh was diagnoised to have PDA heart problem by birth and that was not disclosed at the time of availing the policy. The medical records furnished by the complainant will prove the same. As per the medi claim insurance policy conditions, exclusion Clause No.4(8) the company shall not be liable to make any payment under the policy taken in respect of any expenses whatsoever incurred by any person in connection with or in respect of congenial external disease or defects or anomalies. In this case of Master Adarsh it is case of patent “defect or inborn anomaly” and as such the company is not liable to indemnify the insured. There is no deficiency and malpractice in the service of opposite party. So the complaint is liable to be dismissed with cost.

Both parties filed affidavit and A1 to A4 were marked on the side of the complainant and B1 to B3 were marked on the part of opposite party.

Matter was heard.

Issues to be considered are:

1. Whether there is any deficiency of service or malpractice on the side of opposite party?

2. If so, what is the cost and relief?

The definite of the case of the complainant is that, he and his family members were covered by the medi-claim insurance policy conducted by the opposite party and during the Ist renewal period, the son of the complainant ie, Master Adarsh had undergone an operation and the opposite party has rejected the insurance claim of the complainant. As

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the son of the complainant was covered by the medi-claim insurance policy conducted by the opposite party, they are liable to compensate the complainant and bound to pay an amount of Rs.35,000/- being the medical expenses to the complainant. Where as the main contention of the opposite party is that Master Adarsh had the PDA Heart problem by birth, which was not disclosed at the time of availing the policy.

We have carefully gone through the evidence on record. In discharge summary (Exhibit B1) the doctor clearly stated that “the patient was diagnosed to have a PDA during new born period and was followed up at Amrita Insititute of Medical Sciences. In the medical report of attending doctor which is marked as Exhibit B3, doctor stated that the child was “detected to have PDA during new born period. As per the medi-claim Insurance policy conditions, It is specifically stated that " t]mfnkn FSp¡p¶ kab¯v \nehnenà F¦n t]mepw Xnancw, ssl¸Àt#{Sm¸n IpSend¡w, hrjvW ho¡w, P·\mbpff B´cnI AkpJ§Ä lnÌpe, ssk\sskänkv kw_Ôamb AkpJ§Ä F¶nhbv¡v t]mfnkn FSp¯v BZys¯ Hcp hÀjt¯bv¡v s¢bnan\v AÀlXbnÃ. In this case Master Adarsh was suffering from heart problem by birth is proved by convincing evidence. Further the child is included in the policy at the time of Ist renewal. First year exclusion applicable is specifically stated in the policy also.

So we are not in a position to attribute any deficiency in service or malpractice on the part of opposite party.

In the result complaint dismissed. No order as to cost.

Pronounced in the open court on this the 18^th day of August, 2009

PRESIDENT (SD)

MEMBER (SD)

MEMBER (SD)

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APPENDIX

Witness examined on the side of Complainant

Nil

Witness examined on the side of Opposite party

Nil

Exhibits marked on the side of the complainant

1. Ext. A1 series – Policy schedule of National Insurance Company Ltd

2. Ext .A2 – Details of medi-claim Insurance policy of National Insurance Company Ltd

3. Ext. A3 - Cardia Cathetrization Report of Amrita Institute of Medical Sciences, Cochin

4. Ext A4 - Letter to complainant intimating repudiation dated 10/11/2007

Exhibits marked on the side of the Opposite Party

1. Ext. B1 - Discharge summary of Amrita Institute of Medical Sciences and Research Centre

2. Ext. B2 – Letter of repudiation dated 05/07/2007

3. Ext. B3 - Medical report of attending Doctor dated 14/02/2007

Forums Exhibits

Nil

Forwarded/By Order

Senior Superintendent

Date of fair copy: 26/08/2009