By Smt. Padmini Sudheesh, President: The complainants case is that he was the policyholder of the respondent company under the Group Personal Accident Hospitalisation Benefit Scheme as per policy No.570700/48/2001/850/1789. He was holding policy under the above-mentioned scheme since 1997 and every year the policy is being renewed after paying the necessary premium. The petitioner was under treatment from 7.10.02 to 11.10.02 and 20.10.02 to 30.10.02 at West Fort Hospital, Thrissur for stroke and hypertension. For the continuous treatment for the period 7.10.02 to 30.10.02 the petitioner had submitted claim form together with Mediclaim Medical Report and Mediclaim/Janarogya Bill check. The petitioner had submitted the mediclaim after complying with all the required formalities. But to the utmost dismay of the complainant, as per letter dated 15.12.02 the respondent informed that the claim was rejected stating the reason exclusion No.4.1 of the mediclaim policy. There is no meaning in rejecting the claim. There is deficiency in service in rejecting the claim. Lawyer notice sent on 18.2.03, but no reply and no remedy. Hence this complaint. 2. In the counter respondent stated that this respondent denies the averment in the petition that the petitioner was under treatment in West Fort Hospital from 7.10.02 to 11.10.02 and 20.10.02 to 30.10.02 for stroke and hypertension. This respondent denies the averment in the petition that this respondent has rejected the legitimate claim forwarded by the petitioner without assigning any reason. This respondent denies the averment in the petition that since 1997 the petitioner is renewing the policy. This respondent denies the averment in the petition that this respondent has rejected the claim of the petitioner without assigning any valid reason. The policy taken by the petitioner for the period 9.1.01 to 8.1.03 is a fresh policy and as such any disease that was pre-existing as on 9.1.01 is treated as pre-existing disease and no amount will be payable to the insured. This respondent has paid an amount of Rs.13,156/- during the existence of policy bearing No.570700/48/98/8500471 for the very same diseases for which the petitioner was treated in West Fort Hospital during the year 2002. The policy during the period the earlier payment was made expired on 4.1.2000. The next policy that is policy-bearing No.570700/48/99/8500757 was taken only on 9.1.01. The said policy was for the period 9.1.01 to 8.1.02. As the third policy was renewed without continuity, the diseases which had its onset in the second policy period becomes pre-existing disease as far as the subsequent policies are concerned. The claim made by the petitioner in 1998 shows that the petitioner was having the diseases for which the present claim is made since 1998. The allegation in the complaint that this respondent has rejected the claim on flimsy grounds to escape from the liabilities to pay the claim amount is deficiency of service on the part of this respondent is not correct and is denied by this respondent. The allegation in the complaint that this respondent has committed criminal breach of trust is not correct and is denied by this respondent. The allegation in the complaint that this respondent has not sent any reply to the notice of the complainant dated 18.2.03 is not correct and is denied by this respondent. On getting the notice this respondent was processing the claim of the petitioner and on 10th of March 2003 the company has sent a reply to the petitioner seeking certain clarification regarding his earlier policies. Even without waiting for the reply of this respondent the petitioner has rushed before the Forum as on 10.3.03. This respondent has rightly repudiated the claim vide letter dated 15.12.02 stating the reason pre-existing disease. There is no deficiency in service. 3. An additional counter was also filed by the respondent company stated that it was wrongly mentioned earlier that the policy taken by the petitioner for the period 9.1.01 to 8.1.02 is a fresh policy and as such any disease that was pre-existing as on 9.1.01 is treated as pre-existing disease and no amount will be payable for the insured. Actually the policy for the period 1999-2000 taken by the insured expired on 4.1.2000. Instead of renewing the policy from 4.1.2000 the payment of premium was delayed hence the policy was issued for the period 2000-2001 from 9.1.2000 to 8.1.2001. As such there is a gap of four days in renewing the policy. The policy taken for the period 9.1.2000 to 8.1.01 will be treated as fresh policy and any claim for a disease pre-existing to 9.1.2000 is not payable. So this respondent has rightly repudiated the claim for treatment for the period 7.10.02 to 11.10.02 and 20.10.02 to 30.10.02. Hence dismiss. 4. The points for consideration are: (1) Is there any deficiency in service? (2) Is the complainant is entitled for the amount sought? (3) Other reliefs and costs. 5. The evidence consists of Ext. P1 and R1 to R14. 6. Point No.1: The claim has been rejected by the company stating pre-existence of the disease to 9.1.2000. According to the company, the policy was a new and fresh one. Petitioner stated that the policy is in continuation of the earlier policy. The respondents version is that the policy for the period 1999-2000 taken by the insured expired on 4.1.00. Instead of renewing the policy from 4.1.00 the payment of premium was delayed hence the policy was issued for the period 2000-2001 from 9.1.00 to 8.1.01. Since there is a gap of four days in renewing the policy the next policy is a new and fresh policy. Respondent company produced 14 documents, which are marked as Exts. R1 to R14. The above-mentioned defence of the company cannot be established from the documents produced by the company itself. Ext. R1 is a policy with conditions. That policy is for the period of 9.1.01 to 8.1.02. Ext. R2 is next policy copy in which the period of insurance stated is 9.1.02 to 8.1.03. The policy number stated is 570700/48/01/8501789. During the coverage of this policy the complainant had undergone treatment for 7.10.02 to 11.10.02 and 20.10.02 to 30.10.02. So the treatment can be considered is taken within the policy period. In this aspect complainant is entitled for the policy benefit. Another point to be considered on the pre-existing of the disease. In the counter, the company has stated that the company had paid an amount of Rs.13,156/- for the very same disease for which the petitioner was treated in West Fort Hospital, Thrissur during the year 2002.. Ext. R3 is the claim form in which the amount was paid. In Ext. R3 the date of completion of treatment given is 13.2.02. In the present complaint, the complainant is asked for the expenses during the period from 7.10.02. As per clause 3.0 of the policy condition, occurrence of same illness after a lapse of 45 days will be considered as fresh illness for the purpose of this policy. Hence the contention of pre-existence of the disease will not stand. So the complainant is entitled for the policy benefits. There is deficiency in service on the part of the respondent company. 7. Point No.2 & 3: From the above discussions it is established that the complainant is entitled for the policy benefits. The medical bills are produced by the respondent company and the company has not raised any objection regarding these bills in the counter. So the complainant is entitled for the amount shown in the bills. The bills are covering an amount of Rs.14,239.97. The company had rejected a valid claim without going to the merits of the claim. So the complainant was forced to approach a legal body. Hence he is entitled for compensation of Rs.2000/-. 8. In the result, complaint is allowed and the respondent Company is directed to give Rs.14,240/- (Rupees fourteen thousand two hundred and forty only) as the medical expenses incurred, Rs.2000/- (Rupees two thousand only) towards compensation and Rs.500/- (Rupees five hundred only) as costs to the complainant. Comply the order within one month. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 26th day of August 2008.
