KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAUD THIRUVANANTHAPURAM APPEAL NO.271/07 JUDGMENT DATED 28.10.09 PRESENT JUSTICE SHRI .K.R.UDAYABHANU -- PRESIDENT SRI.M.K.ABDULLA SONA -- MEMBER 1. M/s National Insurance Company Ltd. Branch Office, Kollencherry P.O Ernakulam. 2. M/s.Medi Assist India Pvt.Ltd. -- APPELLANTS 406, Chandralayam, Kurusupally Road, Temple Lane, Ravipuram, Kochi. (By Adv.Prasanna Kumar Nair) Vs. N.M.Kuriakose, Nanchirayil, Kadamattom P.O, -- RESPONDENT Kollencherry, Ernakulam. JUDGMENT JUSTICE SHRI .K.R.UDAYABHANU,PRESIDENT The appellants are the opposite parties in CC. 41/07 in the file of CDRF, Ernakulam. The appellants are under orders to reconsider the claim of the complainant and allow to the extent admissible and also to pay cost of Rs.1000/-. 2. The case of the complainant is that his daughter who is covered by the mediclaim policy was admitted at Kolencherry Medical College Hospital as in patient from 6.3.06 to 11.3.06 for right breast abscess. The treatment charges amounted to Rs.8,500/-. The claim was repudiated on the ground that the treatments with respect to pregnancy illnesses are excluded. 3. The opposite parties have filed separate versions admitting the policy coverage but contending that clause 4.12 of Ext.B1 policy provides for exclusion of treatments expenses arising from or traceable to pregnancy, childbirth, including caesarean section. It is the contention that the assured was a lactating mother and she had normal delivery on 2.12.05. The abscess was on account of Lactational Mastitis and that the experts have considered the claim and rejected on the basis of exclusion of Clause No.4.12 of the policy. 4. The evidence adduced consisted of Exts.A1, A2 and B1 to B3. 5. The Forum has found that the delivery was on 2.12.05 and that the treatment undergone was in March 2006 and hence it cannot be held that the illness related to pregnancy or delivery. The Forum has also noted that no medical opinion has been produced. As pointed out the counsel for the appellant, we find that the above observation of the Forum is incorrect. Ext.B2 is the medical opinion of the opposite parties, medical insurance panel. In Ext.B2, it is mentioned that due to accumulation of milk as stagnation in the milk ducts are blocked the breast abscess is formed. We find that the doctor who issued Ext.B2 has not been examined. It is not evident that breast abscess can be caused on account of not providing breast feeding as pointed out for the counsel for the appellant. It is not evident from Ext.B2 that only on account of the above reason that breast abscess can be caused. It is also to be noted that it is after 3 months of delivery that the assured was hospitalized. In the circumstances, we find that the interference in the order of the Forum is called for. The appeal is dismissed. Return the LCR to the Forum. JUSTICE K.R.UDAYABHANU -- PRESIDENT M.K.ABDULLA SONA -- MEMBER | 
