By Smt. Padmini Sudheesh, President: The case of the petitioner is that the petitioner has joined in a accident mediclaim policy in the name of Union Business Network and Services Ltd. The serial number is 2145 and the code number is 333433. During 14.8.02 to 24.8.02 he was treated in Mother Hospital for Intestinal Tuberculosis with Small Bowel Stricture. Subsequently he had applied for the insurance benefit with sufficient documents. But the claim was not settled. Later lawyer notice sent, but the claim was not settled so far. Hence this complaint. 2. The Company has filed version stating that as per the policy the insured is entitled to a maximum of Rs.15,000/- only towards medical expenses. As per the policy exclusions, the company is not liable to make payment under this policy in connection with or in respect of all diseases, which are pre-existing and any disease during first 30 days from the commencement of the policy. Some specifically mentioned diseases are also excluded. As per medical records it can be seen that the disease has a long duration existing prior to inception of the policy. There is no deficiency of service. Hence dismiss. 3. The points that arise for consideration are the following. (1) Whether the complainant is entitled for the medical expenses as claimed? (2) Whether there is deficiency of service? (3) Reliefs and costs. 4. The evidence consists of Exts. P1 to P3 and the statement of RW1 and Exts. R1 to R6 series. 5. Points: The entitlement of the petitioner for insurance benefit is to be decided. During the insurance coverage the complainant has undergone treatment for Intestinal Tuberculosis with Small Bowel Stricture and occurred medical expenses of Rs.23,177/- only. He has applied for the claim. But it was not settled stating he was suffering from the disease for a long duration and it cannot be of a sudden onset one. The reliable document is Ext. R1. Ext. R1 doctors record from Mother Hospital, Thrissur there is a correction in second page. During examination that correction is clarified and the witness deposed that it is since two months and not since two years. Then it is made clear that the disease was not happened all on a sudden. On 14.8.02, the doctor has certified that having abdominal pain since two months. The duration of the policy was 14.1.02 to 14.1.03, the consultation and treatment are within the period. More over the disease was started in the insurance period also. There is no justification in not settling the claim. Hence there is deficiency in service on the part of the Company and the Company is liable to provide the expenses. As per the policy the insured person is entitled to a maximum of Rs.15,000/- only and the complainant is only entitled for the amount. 6. In the result, the complaint is allowed and the respondent Company is directed to pay Rs.15,000/- (Rupees fifteen thousand only) with interest at the rate of 12% per month till realisation. The respondent is further directed to pay Rs.2000/- (Rupees two thousand only) towards costs. Comply the order within a month. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 28th day of July 2008.
