ORDER

NIPUR CHANDNA, MEMBER



 Complainant purchased famly health protection insurecanc policy from
OP1 for the period from 8-8-2013 to 7-8-2014. It is alleged by the
complainant that as he had some problem in his left ear,he approached
OP3for the treatment on 8-11-2013 and on the advise of OP2 he admitted
himself with OP3 . OP2 had conductd an operation on himn on
30-11-2013.

     It is further alleged by the complainant that he was discharged
from the hospital on 1-12-2013 and an amount of Rs. 53,002/- was spent
by him on his treatment.

     It is alleged by the complainant that after discharge he
submitted his claim for reimbursement to OP1. It is further alleged by
the complainant that OP1 rejected his claim on the ground that in the
discharge summary there was an overwriting which suggested the disease
was a pre-existing one and such the claim is not payable.

     It is further alleged by the complainant he approached OP2 and 3
requested them to issue discharge summary as the first discharge
summary  contained the over writng. OP2 and 3 again issued a fresh
discharge summary with a forwarding letter to OP1 that the overwriting
on the discharge summary was done by mistake while writing the same.

     The complainant with the re-issued discharge summary again
requested OP1  vide its letter dated 21.01.2014 to re-process his
claim. OP1 vide its letter dated 6-2-2014  affirmed its decision of
repudiation of claim.

     It is alleged by the complainant that the OP had repudiated his
claim on false and flimsy grounds which amounts to deficiency in
services. Hence , this complaint.

     Ops have contested the complaint that the OP had repudiated his
claim on false and frivolous grounds which amounts to deficiency in
services. Hence, this complaint

     Ops have contested the complaint and filed  written statement.
Paras no. 4, 5 and 7 of the written statement filed by OP1 is relevant
to decide this complaint and are reproduced as under:-

4.It is stated that the discharge summary of the M/s.Bali Nurshing
home clearly showed that the complainant was suffering from the
aliment since past 4 months as the same was categorically mentioned in
the discharge summary though some overwriting was done to change the
same into two months, therefore the same proved that the complainant
was sfrom the aliment even before the policy was taken from the
opposite party i.e. if 4 months is to be reckoned from 01.12.2013
onwards then the aliment should have commenced on 30.07.2013 and the
said date is much prior to the policy inception as the policy was
taken by the complainant only on 08.08.2013. This fact clearly shows
that the complainant had developed the aliment and had ear discharge
much prior to policy inception and the said fact proves that the claim
being made by the complainant was for preexisting aliment and
therefore the same was inadmissible under the policy as all claims
pertaining to pre- existing diseases are specifically excluded from
the policy issued to the complainant.

5) It is stated that the complainant had the aliment since 30.07.2013
and the policy was taken from the opposite party from 08.08.2013
onwards and the same conclusively proves that the complainant was
suffering from the aliment of Large TM perforation in left ear even
before taking policy from the opposite party. Though the complainant
as an after-thought had produced a letter from the 2nd opposite party
dated 13.01.2014 stating that the aliment history was from 2 months
only and not 4 months as the same had been wrongly noted by the 2nd
opposite party treating doctor, and such letter as procured by the
complainant from the 2nd opposite party is untenable as the same was
to cover-up the issue of pre-existing aliment, as such otherwise the
complainant very well knew that his claim was inadmissible under the
terms of the policy.

7. ) It is humbly submitted that the pre-existing diseases is
specifically excluded from the terms and conditions of the policy. The
relevant condition of the exclusion clause is reproduced below for the
kind reference of the Hon'ble Forrn-



D. EXCLUSIONS

The Company shall not be liable under this Policy for any claim in
connection with or in respect of: Any pre existing condition(s) as
defined in the policy, until 48 months of continuous coverage have
elapsed, since inception of the first Family Health Protector
Insurance with us.

Pre existing Condition

Pre-Existing Condition means any condition, ailment or injury or
related condition(s) for which you had signs or symptoms and/or were
diagnosed and/or received medical advice/ treatment, within 48 months
prior to your first family health protector policy with us.

   Both the parties have filed their evidence by way of affidavits.

     We have heard arguments advanced at the bar and have perused the record.

     Counsel for OP1 has contended that the complainant was suffering
from the ailment since past four months and the same was categorically
mentioned in the discharge summary though some over writing was done
to change the same into two months.  It is further contended by the
counsel for OP1 that as per discharge summary, the patient was
suffering from ailment from the past four monthis i.e. prior to the
inception of the policy and as such his disease will be treated as
pre- existing as per the policy terms and  conditions , all the claims
pertaining to pre-existing disease are specifically excluded and
therefore, the claim of the complainant was rightly repudiated by OP1.

     It is further contended by the counsel for OP1 that the
complainant claim was carefully scrutinized on the basis of available
records and discharge summary in accordance with the policy terms and
conditions and as such there is no deficiency in service on its part
and prayed for dismissal of his complaint.

     Counsel for OP2 and OP3 has contested that as they had already
made necessary correction in the discharge summary and even  wrote
apologies letter to the OP , they are not guilty of any deficiency in
service.

     Counsel for the complainant on the other hand stated that the OP
had repudiated the claim on false and flimsy grounds. It is contended
that the case of the complainant does not fall under the ambit of
pre-existing disease, because the complainant was neither aware nor
had any sign or symptom of the ailment before and after inception of
the policy. It is contended by the counsel for the complainant that
there is some overwriting about history of disease in the discharge
summary.   The aforesaid mistake was rectified by OP2 and 3 with the
re-issued discharge summary and an apologize letter dated 13-1-2014
was also addressed to by OP1.

     It is further stated by the counsel for the complainanat that
despite the reissued discharge summary OP1 had failed to reimburse the
claim of the complainant and had repudiated the same on false and
flimsily grounds.

     On the basis of above contentions , and the documents placed on
record, we are of the considered opinion that the case of the
complainant does not fall within the ambit of pre-existing disease
which was itself proved by the re-issued discharge summary and the
letter dated 13.1.2014 issued by OP2 and 3.

     Op1 had repudiated the claim of the complainant without
considering the re-issued discharge summary and letter dated 13-1-2014
on false and flimsy grounds. A part from the fact that the discharge
summary had an overwriting about the period for which the complainant
was suffering from the disease, there is no other documents with OP1
to prove that this disease was pre=existing.  The TPA who had
interrupted the matter had also failed to place on record any material
suggesting that the disease was preexisting prior to the inception  of
the policy. Therefore, the reliance on a entry in the discharge
summary to repudiate the calim was uncalled-for.

 We therefore, hold OP1 guilty of deficiency in service and direct it as under;

1.   To pay to the complainant Rs 53,002/- alongiwht interest @ 10%
p.a. from the date of filing of this complaint i.e. 28.2.2014 till
payment.

2.   To pay to the complainant a sum of Rs. 10,000/- for mental pain
and  mental agony suffered by him.

3.   To pay to the complainant a sum of Rs. 5000/- as cost of litigation.

                The OP shall pay this amount within a period of 30
days from the date of this order failing which they shall be liable to
pay interest on the entire awarded amount @ 10% per annum.  IF the OP
fails to comply with this order, the complainant may approach this
Forum for execution of the order under Section 25/27 of the Consumer
Protection Act.

     Copy of the order be made available to the parties as per rule.

    File be consigned to record room.

     Announced in open sitting of the Forum on.....................