1) In brief consumer dispute is as under –

   That the deceased Complainant had taken Mediclaim Policy from the Opposite Party No.1 in 1993. Thereafter the Complainant regularly renewed the said policy without any break on payment of necessary premium. Alongwith the complaint the Complainant has produced photo copy of mediclaim policy issued by the Opposite Party No.1 from 15/02/1993 to 14/02/1994 and subsequent renewed mediclaim policies till 14/02/2006. Opposite Party No.2 is the T.P.A. of the Opposite Party No.1.
 

2) It is submitted that the Complainant had no health problem till the year 2001. For the first time in 2001 Complainant developed health problem and he was required hospitalization due to kidney malfunctioning. The Complainant was admitted in the H.N. Hospital from 20/03/2001 to 29/03/2001 for treatment. After discharge from the hospital the Complainant lodged his claim with Opposite Party No.1 for reimbursement of the hospital expenses of Rs.29,621/-. On 08/06/2001 Opposite Party No.1 paid aforesaid claim amount to the Complainant. In the year 2002 and about beginning of 2003, the Complainant was again hospitalized for his kidney ailments and after discharge from the hospital he lodged claim to Opposite Party No.1 for Rs.35,977/- and Rs.75,345/-. After processing aforesaid claims, the Opposite Party paid to the Complainant Rs.35,877/- on 15/02/2003 and Rs.73,098/- on 08/12/2003.
 

3) It is submitted that Opposite Party No.1 became aware about Complainants ailments in the year 2001 even then the Opposite Party renewed mediclaim policy of the Complainant from time to time.
 

4) It is submitted during subsistence of mediclaim policy, the Complainant was required to go for dialysis treatment for his kidney ailments in Sanjeevani Hospital from 07/01/2005 to 12/01/2005 and again on 21/01/2005 to 20/02/2005. For medical treatment during the aforesaid period, the Complainant incurred total expenses of Rs.2,53,415/-. Thereafter the Complainant lodged his claim with Opposite Party and submitted necessary medical papers and medical bills alongwith the claim form.
 

5) It is the say of the Complainant that by letter dtd.27/05/2005 Opposite Party No.2 rejected his claim on false and flimsy grounds stating therein that the said claim falls under pre-existing condition. Alongwith the complaint, the Complainant has produced photo copy of repudiation letter 27/05/2005. According to the Complainant, rejection of claim is against the terms and conditions of mediclaim policy. Opposite Party have illegally rejected his claim without application of mind and it amounts to deficiency in service and unfair trade practice on the part of Opposite Parties. Therefore, the Complainant has filed this complaint and requested to direct Opposite Parties to pay claim amount of Rs.2,53,415/- to the Complainant with interest @ 12 % p.a. from the date of claim till payment. The Complainant has claimed Rs.25,000/- as compensation for harassment and mental agony and Rs.25,000/- towards cost of this complaint.
 

6) Opposite Party No.1 has filed written statement and thereby resisted claim of the Complainant contending interalia that allegations made in the complaint are false. The Complainant has suppressed material facts from the Opposite Party and therefore, complaint deserves to be dismissed with cost.
 

7) Opposite Party No.1 has admitted that the Complainant Kamlesh Patel had obtained mediclaim policy from the Opposite Party No.1 for the first time on 15/02/1993 and said policy was for one year and further it was renewed from time to time. At the time of taking of the policy the Complainant had declared that he was not suffering from any ailment.
 

8) The Complainant was reportedly admitted on 07/01/2005 and again on 21/01/2005 at Sanjeevani Nursing Home for Acute Renal Failure due to Adult Type Polycystic Kidney Disease (ADPKD). The Complainant submitted claim of Rs.2,53,415/- to the Opposite Party alongwith medical papers. Then Opposite Party referred medical case papers for opinion to the Panel doctor of TPA. After perusal of the said papers, Panel doctor noticed that the Complainant had given a clear-cut history of being a case of ADPKD since 1992 from history papers of the Bombay Hospital in a previous admission. The said ailment was pre-existing and led to kidney failure.
 

9) It is submitted that mediclaim policy issued to the Complainant excludes all the ailments arising out of disease which are pre-existing, therefore, the Complainants’ claim was repudiated. It is alleged that the Complainant never disclosed the fact of his previous ailment in the Proposal Form, which in effect a non-disclosure of material facts, a further cause to repudiate the claim.
 

10) Opposite Party No.1 has denied all the allegations made in the complaint and submitted that Discharge Card of Bombay Hospital clearly states that the Complainant had ADPKD since 1992. The facts that Complainant claim was paid in 2002 and 2003 does not derogates from the fact that the ailment was pre-existing.
 

11) It is submitted by Opposite Party that mediclaim policy of the Complainant was renewed on the basis of knowledge as and then available. The incidence of fraud was discovered only during processing of subsequent claim. There is no substance in the allegations made in the complaint that claim was repudiated in contravention of the terms and conditions of the policies. There is no deficiency in service on the part of Opposite Party and therefore complaint deserves to be dismissed with cost.
 

12) It appears from the Roznama that Opposite Party No.2 was duly served with the notice but he is not appeared before this Forum and has not filed written statement.
 

13) Alongwith the complaint the Complainant has produced documents as per list of document. Opposite Party has filed affidavit of Vijay R.Bhaillume, Sr. Manager in support of the contention of written statement and have produced Standard Form of Mediclaim Insurance Policy. Photo copy of the discharge summery of Bombay Hospital dtd.27/07/07, photo copy of the claims form, medical literature regarding Chronic Renal failure, etc.
 

14) During pendency of this complaint, original Complainant Mr.Kamlesh Patel expired on 21/01/2008. Thereafter heirs of deceased Complainant were brought on the record. Heirs of the deceased Complainant whose names are brought on the record have filed claim affidavit.
 

15) The Complainants have filed written argument. Opposite Party No.1 has also filed written argument. After filing of written argument from 02/07/09, the Complainant’s have not appeared before this Forum and on the ground of absence of Complainant from time to time matter was adjourned for oral argument. Therefore, on 17/06/2010 oral submissions of Ld.Advocate, Mr.Manoj Mhatre for Opposite Party No.1 were heard and the complaint was closed for order.
 

Point No.1 :- It is admitted fact that deceased Complainant Mr.Kamlesh Patel had taken Mediclaim Policy from Opposite Party No.1 on 15/02/1993 and the said policy was for 1 year. It is not dispute that thereafter from time to time after payment of premium Opposite Party No.1 renewed mediclaim policy of the Complainant till 14/02/06.
 

        It is the case of the Complainant that even though he had taken mediclaim from Opposite Party No.1 in the year 1993, he had no health problem till 2001. As such, he had never claimed any amount from the Opposite Party No.1 under any Mediclaim Policy till 2001. As per the Complainant, in the year 2001 due to malfunctioning of Kidney he was admitted in the H.N.Hospital from 20/03/2001 to 29/03/2001 for treatment. After discharge from the hospital he had preferred claim with Opposite Party No.1 for reimbursement of the hospital expenses of Rs.29,621/- and the Opposite Party No.1 has paid the said amount to him on 08/06/01. Subsequently in the year 2003 and about beginning of 2003 the Complainant was again hospitalized for kidney ailment and then he lodged complaint against Opposite Party No.1 for Rs.35,977/- and for Rs.75,345/-. Opposite Party after processing his claim paid him Rs.35,877/- and Rs.75,345/- on 08/12/2003. Aforesaid fact of settlement of Complainants claim is admitted by Opposite Party No.1.
 

 

       As per the Complainant, during subsistence of his mediclaim policy during the period from 07/01/05 to 12/01/05 and again from 21/01/05 to 20/02/05 he took treatment for kidney ailment in Sanjeevani Hospital and after discharge from the hospital he preferred claim for reimbursement of hospital charges of Rs.2,53,415/- from Opposite Party No.1 and alongwith claim form he submitted necessary medical papers and bills. The fact that the Complainant had submitted claim form for reimbursement of hospital expenses of Rs.2,53,415/- to Opposite Party No.1 alongwith medical case papers which is admitted by Opposite Party No.1. Further it is undisputed fact that Opposite Party No.2 by letter dated 27/05/05 rejected aforesaid claim of the Complainant on the ground that the claim falls under pre-existing condition and the claim was rejected as per the exclusion clause no.4.1 of the said policy.
 

      It is submitted by the Complainant that the Opposite Party has rejected claim on faulty and flimsy ground and rejection of claim is against terms and conditions of mediclaim policy and it amounts to deficiency in service on the part of Opposite Parties.
 

       As mentioned above, according to the Complainant till 2001 he was not suffering from any health problem and for the first time in the year 2001 he suffered from kidney ailment. On the contrary according to the Opposite Party No.1, the Complainant was suffering from kidney ailment since 1992. Ld.Advocate Mr.Manoj Mhatre had submitted that even though the Complainant was suffering from kidney ailment from 1992 at the time of taking of mediclaim policy, deceased Complainant did not disclose to the Opposite Party about his ailment. The deceased Complainant suppressed the material facts from the Opposite Party and fraudulently obtained the mediclaim policy. On good faith Opposite Party No.1 renewed the said policy from time to time. For the first time when the Complainant submitted his claim form for reimbursement of hospitalization charges of Rs.2,53,415/-, the Complainant sent medical case papers to the panel doctor of Opposite Party No.2 for scrutiny. After scrutiny of case papers panel doctor noticed that in the discharge form of Bombay Hospital, it is noted that the Complainant is suffering from ADPKD from 1992. In this case Opposite Party had not produced opinion of the aforesaid panel doctor. The Ld.Advocate for the Opposite Party No.1 to support his contention that the Complainant was suffering from ADPKD from 1992 has relied upon medical history written in the discharge summery of the Bombay Hospital. Photocopy of discharge summary of the Bombay Hospital is produced on record by the Opposite Party No.1.
 

        Absolutely there is no evidence on record to show that prior to inception of the mediclaim policy i.e. prior to 15/02/1993 the Complainant had taken any medical treatment for alleged kidney ailment. As mentioned above, as per the Opposite Party No.1 came to know about pre-existing disease. After receipt of opinion of Panel Doctor in the year 2005. In the matter of New India Assurance Co.Ltd. V/s. Mohinder Kaur reported in 2008 CTJ 780 (CP) (SCDRC) State Consumer Dispute Redressal Commission, Punjab, Chandigarh – it is held that “A mere history given in the hospital ipso facto is of no consequence as history alone cannot be treated as valid ground to repudiate a claim, while it is a settled law that in case of fraudulent suppression of material information onus heavily rests on the party alleging fraud”.
 

        In the instance case besides photo copy of the discharge summery of Bombay Hospital the Opposite Party No.1 has not adduced any evidence to prove the allegations that the Complainant was suffering from kidney ailment prior to inception of mediclaim policy in 1993 and the Complainant has suppressed material fact regarding his health from Opposite Party No.1. In aforesaid judgement it is clearly led down that mere history given in the hospital ipso facto is of no consequence as history alone cannot be treated as valid ground to repudiate a claim. Therefore, it appears that the Opposite Parties have repudiated claim of the Complainant without any reliable evidence and therefore, repudiation of claim amounts to deficiency in service on the part of Opposite Parties. Therefore, we answer point no.1 in the affirmative.
 

Point No.2 :- The Complainant has prayed for reimbursement of the hospitalization expenses of Rs.2,53,415/- under the mediclaim policies issued by the Opposite Party. As per the Complainant, firstly on 07/01/05 to 12/01/05 he was admitted in Sanjeevani Hospital for kidney ailment and for second time he was admitted in the same hospital for kidney ailment from 21/01/05 to 20/02/05. Alongwith complaint, the Complainant has produced photo copies of mediclaim policies issued by the Opposite Party from 15/02/1993 onwards till 16/02/07. The Complainant’s aforesaid claim is covered under 2 policies first policy bearing no.140100/48/03/11523 the said policy was for the period from 15/02/04 to 14/02/05. First hospitalization period from 07/01/05 to 12/01/05 is covered under this policy. Photo copy of which is produced at page no.18, sum assured in the policy for deceased Complainant Mr.Kamlesh Patel was Rs.1,20,000/- + 1,30,000/-. Second period of hospitalization 21/01/05 to 20/02/05 is covered under policy no.140100/48/04/85172. The said policy for the period from 15/02/05 to 14/02/06. the photo copy of which is produced at page no.6, sum assured in the policy for deceased Complainant Mr.Kamlesh Patel was Rs.1,20,000/- + 1,30,000/-. It is not case of the Opposite Party that during period of earlier policy whichwas for the period from 15/02/04 to 14/02/05 the Complainant had preferred any other claim. Therefore, we hold that under the above said 2 policies for the period from 15/02/04 to 14/02/05 and 15/02/05 to 14/02/06 the Complainant is entitled to recover Rs.2,53,415/- from the Opposite Party.
 

         The Complainant has prayed for interest @ 12 % p.a. from the date of payment on the aforesaid amount. The Complainant has claimed interest at excessive rate. It appears from the facts on the record that Opposite Party vide letter dtd.27/05/05 rejected claim of the Complainant on the ground of pre-existing disease. The claim was wrongly rejected by the Opposite Parties. Therefore, the Complainant is entitled to recover Rs.2,53,415/- from the Opposite Party. Therefore, we think it just to direct Opposite Parties to pay interest on Rs.2,53,415/- to the Complainant from 27/05/05 @ 9 % till realization of entire amount to the Complainant.
 

         The Complainant has claimed Rs.25,000/- for mental agony and harassment and Rs.25,000/- towards cost of this complaint. Opposite Party has rejected the Complainant’s claim as well compensation and cost of this complaint. As discussed above, the Opposite Party has wrongly rejected Complainant’s claim for reimbursement to the aforesaid amount. Considering the facts and circumstances of the case, we think it just to direct Opposite Party to pay Rs.3,000/- as compensation for mental agony and harassment and Rs.1,000/- as cost of proceeding to the Complainant. Hence, we answer point no.2 accordingly.
 

For the reasons discussed above, we partly allowed the complaint and pass following order –
 

O R D E R

 

i.  Complaint No.254/2006 is partly allowed.
 

    the Complainant with interest @ 9 % p.a. on aforesaid amount from 27/05/2005 till realization of entire amount to the Complainant.
 

    (Rs.One Thousand Only) as cost of proceeding to the Complainant.
 

iv.Opposite Parties Nos.1 & 2 shall comply with the order within period of 1 month from the date of receipt of this order.