By Smt. Padmini Sudheesh, President: The averments in the complaint is as follows: Complainant was a policy holder of respondent company by Pravasi Suraksha Insurance Scheme vide policy No.H001050994/2000-2001. She had a fall and admitted in hospital on 18.6.01 and discharged on 3.7.01. She had undergone an operation and incurred Rs.25,707/- as medical expenses. The complainant applied for the insurance claim with all the relevant documents but was rejected stating the reason that false declaration was furnished to the company. This act of respondent is deficiency in service. Hence this complaint. 2. The averments in the counter is as follows: The respondent denies all the material allegations except those admitted. There is no unfair trade practice and there is no deficiency in service. The policy has issued under the policy No.H 001050994/2000-2001 for a period from 31.3.01 to 31.3.06 under the Pravasi Suraksha and Kudumba Arogya Scheme in favour of P. Mohammed Ali, P.B.No.2899, Riyadh subject to the terms and conditions. The complainant has to prove the facts stated in Para No.3 of the petition. The petitioner has to prove that she has spent Rs.25,707/- by way of medical expense for her alleged treatment. This respondent admitted that they have repudiated the claim on the ground of false declaration by way of suppressing material facts and this was duly intimated to the petitioner vide letter dated 31.10.01. The petitioner has submitted a claim on 11.7.01 along with medical records. On going through the records these respondents find some discrepancies in the records and for clarification of doubts they have obtained a medical certificate from attending doctor of West Fort Hospital, Thrissur, in which the petitioner was last treated, shows that the insured person was having Parkinson disease and hypertension for the past 4 years. The patients with above disease are liable for fall after giddiness or loss of balance and the patients could have sustained injuries as a result of fall, which could have resulted by the illness. The allegation that the medical record does not in any way substantiate the grand of repudiation of claim of the complainant is not correct and denied. The repudiation is based on the condition 2 of the policy. As the answer to questions 5(a), 5(b), 6(a) and 6(b) which relates to previous history of illness is not true. In the above circumstances, as per condition IX.2 of the policy as the answer to questions 5(a), 5(b), 6(a) and 6(b), which relates to previous history of illness is not true in the above circumstances. As per condition IX.2 of the policy the company shall not be liable to make payment under this scheme in respect of expenses whatsoever incurred by as far any insured person in connection with treatment. The complainant has purposely suppressed the material facts from the insurance company. The claim preferred by the complainant is for a disease, which has pre-existing to the petitioner, and being fully aware that she has the ailment prior to issue of the policy. In the light of findings of our investigations which is also confirmed by the doctor that the disease is a pre-existing one this respondent has no liability to pay any amount to the complainant as claimed in the complaint. The repudiation is based on the policy conditions and the complaint is liable to be dismissed. 3. The points for consideration are: (1) Is there any deficiency in service? (2) Is the complainant entitled for the policy benefit? (3) Other reliefs and costs. 4. The evidence consists of Exts. P1 and P2 and Ext. R1 to R8, and the statement of RW1. 5. Points-1 to 3: According to the complainant, she was a policy holder of Pravsi Suraksha Insurance Policy vide policy No.H 001050994/2000-2001. She had fallen and sustained fracture and admitted in West Fort Hospital, Thrissur on 18.6.01. She had undergone an operation and discharged on 3.7.01. The medical expenses incurred was Rs.25,707/-. The treatment was within the period of insurance policy. So she had applied for the insurance claim, but was rejected by the company stating pre-existence of the disease and suppression of material facts. Exts. P1 and P2 are the documents produced by the complainant. Ext. P1 is the policy copy by which it can be seen that P.Mohammad Ali is the policyholder and the family members are having the coverage of policy. Thus the complainant included in the purview of the policy. In the counter respondent also stated this fact. The main defence of the respondent is that the complainant was having Parkinson disease and hypertension for the past four years and the patients with this disease are liable for fall after giddiness or loss of balance and the patients could have sustained injuries as a result of fall, which could have resulted by the illness. The respondent company affirmed their version by relying Ext. P6 document. In Ext. P6 the attending doctor stated that the complainant was having Parkinson disease and hypertension for the past four years. The doctor is examined as RW1 and during the chief examination he has sticked on his version. He also added that the patients of this disease are liable for fall after giddiness and sustaining of injuries. He again stated that the details are disclosed by the complainant herself. During the cross examination he has deposed that he has realized the disease of complainant from her tongue and also from the medicines took by her. At the time of consultation of RW1 by the complainant he has understood that she is using the medicines for Parkinson. The period was stated by the complainant herself. There is nothing to disbelieve the words of RW1. A patient at that situation would not lie to a doctor. The evidence given by RW1 is trustworthy and can be taken into consideration. From the above discussion it is clear that she had prior consultation with some other doctor for Parkinson disease and she was using medicines for the said disease. The pre-existence of the ailment and the knowledge about it suppressed by the complainant. The nature of the patients suffering from this disease is already explained. During the re-examination also he has deposed that Ext. P5 document is the evidence for her disease. So the complainant willfully suppressed this fact at the time of joining the policy. It is evidenced by Ext. R1. Hence there is no deficiency in service in repudiating the claim and the complaint is liable to be dismissed. 6. In the result, the complaint is dismissed. No order as to costs. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 19th day of September 2008.
