By Smt. Padmini Sudheesh, President<br /> <br /> The case of the complainant is that he was a Medi-claim Insurance policy holder<br /> of respondent company vide Policy No.2001/8500204and the policy period was 19/4/01 to 19/4/02. This policy was in continuation of the earlier policy. On 11/4/02 he was admitted in Amala Hospital, Thrissur for treatment for the disease affecting lungs and discharged on 12/4/02. After that he had applied with all relevant documents for the insurance benefits. But it was rejected. Earlier petitioner had received amount for the treatment and the rejection of the present claim was without any basis. There was deficiency in service. Hence this complaint.<br /> <br /> The case of respondent is that the respondent denies the averment in the claim that the denial of the claim is unjustifiable. The petitioner was admitted in Amala Hospital for cough and other connected diseases. The petitioner himself has admitted in his letter to this respondent that he was suffering from cough and sneezing for the last two years and was under the treatment of Dr.Victor of Padua Hospital, Puthenpeedika, Dr.Sanoj of Mother Hospital and now under the treatment of Dr.Shobha Subramanian for the same. In the Medical Report given by Dr.Victor of Padua Hospital he has certified that the petitioner was under his treatment since 2000 January for the disease for which he was admitted in Amala Hospital. The policy mentioned in the petition covers the period 20/4/2001 to 19/4/2002. The petitioner’s claim was not entertained under the policy as per exclusion clause No.4-1 of the policy as per existing disease. The claim was repudiated on the basis of medical records as well as on the basis of the report submitted by the investigator. The petitioner was admitted in Amala Hospital for cough and other connected disease. The respondent has rightly repudiated the claim after going through the medical records and report submitted by the Insurance Claim Investigator appointed by the respondent company. There is no deficiency in service. This respondent is not liable to pay Rs.7,000/- as claim amount and compensation. Hence dismiss the complaint.<br /> <br /> 3. The points for consideration are<br /> 1) Is there any deficiency in service on the part of Company ?<br /> 2) If so reliefs and costs ?<br /> <br /> 4. The evidence consists of Exhibits R1 to R11. The treated doctor is examined as RW1.<br /> <br /> 5. Points : The definite case of complainant is that during the policy period he had undergone treatment for lungs disease and some amount had incurred for the treatment. As per the medi-claim policy he is entitled for the policy benefits. But his claim had rejected by the company stating that he was suffering from the disease long before the policy and hence not entitled for the benefits. There are eleven documents produced and marked. In Exhibit R2 the complainant had revealed that he was suffering the disease for four months. Exhibit R3 is the medical report issued by Dr.Victor who had treated the complainant had sated that the date of first consultation was in the year 2000 January. He was also examined as RW and he deposed that from January 2000 the complainant had such diseases. During the cross examination he had stated that only after referring the records such kind of certificates are issued. Hence it is clear that the complainant was suffering from the disease before the policy and the consultation and treatment were done as stated by the doctor and documents. The rejection of policy on the ground of preexisting disease was right. The statement given by the doctor shows that this person was suffering from the disease from 2000 onwards. At the time of joining the policy the complainant had suppressed this fact. Hence there is no deficiency in service on the part of respondent company.<br /> <br /> 6. The complainant had stated that the present policy is in continuation of the earlier policy. But there is nothing to show this fact.<br /> <br /> 7. In the result the complaint is dismissed. No cost and compensation.<br /> <br /> Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open Forum this the 6th day of September 2008.<br />