O R D E R

A. Rajesh, President.

1. The case of the complainant is as follows :

The complainant was a mediclaim policy holder of the 1^st opposite party. While so, his wife Remani was admitted in the Amrita Institute of Medical Science on 03-05-2006 with complaint of chest discomfort. She was discharged on 04-05-2006. Rs. 9,612/- was incurred towards treatment expenses. A claim was lodged before the opposite parties. But it was repudiated by the 2^nd opposite party by their letter dated 01-12-2006. The reason given for repudiation is that the disease was pre-existing. Against the repudiation, a complaint was given to the 1^st opposite party. The 1^st opposite party as well repudiated the claim. The reason given for repudiation is not correct and hence unsustainable. Though Smt. Remani had consulted a doctor on 27-07-2004 with chest discomfort, no treatment was prescribed to her since after investigation it was found that she had no problem related to chest. Hence the allegation of pre-existing disease is not sustainable. Therefore, the complainant is entitled to the claim amount of Rs. 9,612/- with interest at the rate of 12% p.a. from the date of claim till realisation. He is also entitled for Rs. 2,000/- towards compensation for the mental agony and hardships suffered by him due to the repudiation of the claim. He is also entitled for costs of the proceedings. Hence this complaint.

2. Version of the 1^st and 2^nd opposite parties :

The mediclaim policy was valid from 17-08-2004 to 16-08-2005 and from 17-08-2005 to 16-08-2006. The claim of the complainant is covered by Exclusion Clause 4.1 of the policy, since the disease of the wife of the complainant was pre-existing. She is having the treated illness even prior to the commencement of the policy. The complainant is not entitled to get any of the reliefs claimed for.

3. No oral evidence was adduced by the complainant. Ext. A1 was marked on his side. The witness for the 1^st opposite party was examined as DW1 and Exts. B1 to B5 were marked on the side of the 1^st opposite party. Heard the counsel for the parties.

4. The points that arose for consideration are :-

1. Whether the complaint is maintainable?

2. Whether the complainant is entitled to get insurance claim from the opposite parties?

3. Compensation and costs of the proceedings?

5. Point No. i. :- At the threshold, the 1^st opposite party filed I.A. 300/2008 challenging the maintainability of the complaint. This Forum vide order dated 20-05-2010 found that the complaint is maintainable in this Forum. The order has not been challenged by the opposite parties. So, further discussion in this point is not at all warranted closed hence.

6. Point No. ii. :- According to the complainant, the treatment availed by the patient in 2004 was not for any heart ailment and there was no suppression of ailment at the time of inception of the policy. However, the opposite party vehemently contended that the medical records go to show that the patient was suffering from heart ailment and the claim is not payable as per the terms and conditions of the insurance policy.

7. Admittedly, the complainant's wife had undergone treatment in Amruta Institute of Medical Sciences, Kochi for a day from 03-05-2006 to 04-05-2006. Her disease was diagnosed as chest discomfort for evaluation, normal epicardial coronaries systemic hypertension, Dyslipidemia APD” evidenced by Ext. B1. In Ext. B1 the history of the patient is stated as follows :

“Mrs. Ramani 56 year old patient known hypertensive and dyslipidemic has been experiencing chest discomfort on exertion since 2 years. A TMT done in 2004 was reported positive for inducible ischemia. She had 2 to 3 episodes of accelerated hypertension with sweating for which she was evaluated outside and was referred here for further evaluation and management. Presently patient is admitted here for coronary angiogram.”

8. The doctor who treated the patient was examined as DW1. The case sheet of the patient was produced by the witness, the relevant page pertaining to the treatment on 27-07-2004 and 30-11-2004 was marked as Ext. B2. The deposition of DW1 and Ext. B2 would go to show that nothing abnormal has been detected on the patient, while she was treated at the hospital on 27-07-2004 for reason obviously referred to above. So, we are not to agree with the contention of the opposite party that the disease of the complainant was pre-existing prior to the inception of the policy. In view of the above, we are only to hold that the complainant is entitled to get insurance claim from the 1^st opposite party for his treatment of the wife from 03-05-2006 to 04-05-2006.

9. Since the primary grievance of the complainant has been met primarily no order as to compensation or costs are called for.

10. In the result, we partly allow the complaint and direct that the 1^st opposite party shall pay the insurance claim of the complainant together with 9% p.a. from the date of complaint till payment.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.

Pronounced in open Forum on this the 8^th day of July 2011.