SRI.K. VIJAYAKUMARAN, PRESIDENT. Complaint claiming insurance amount compensation, costs etc. The averments in the complaint can be briefly summarized as follows: The complainant is an insured of the opp.party under Universal Health Insurance Policy dated 25.12.2006 he has renewed the policy on 26.12.2007. On 3.3.08he was admitted in the Upasana Hospital for Hernia surgery and HAD under gone SURGERY on 5.3.08. He preferred a claim for Rs.15,450/- towards hospital expenses. But his claim was repudiated on the ground that he has pre-existing disease. The repudiation is illegal and hence the complaint. The opp.party 1 and 2 filed a joint version contending, interalia, that the complaint is not maintainable. The complainant is not a consumer within the meaning of Section 2[1] of the Consumer Protection Act. It is admitted that the opp.party had issued a Universal Health Insurance Policy to the complainant and his family members to an insured a sum of Rs.30,000/- each for a period commencing from 27.12.2007 to26.12.2008. The complainant had undergone surgical treatment or his disease of inguinal Hernia [Rt] at Upasana Hospital, Kollam and reported a claim. After getting the claim the office appointed a private investigator with regard to the duration of the disease and the previous disease if any. The investigator after investigation filed a report that the complainant was suffering from inguinal Hernia since 5 years from the date of his admission at the Upasana Hospital. The complainant had deliberately suppressed his disease at the time of submitting proposal. As per the exclusion clause 4 [1] of the insurance policy, the company will not be liable under the policy in respect of any expenses incurred by the insured person in respect of disease which are pre-existing. There is no deficiency in service on the part of the opp.party. Hence the opp.party prays to dismiss the complaint. Points that would arise for consideration are: 1. Whether there is deficiency in service on the part of the opp.parties 2. Reliefs and costs. For the complainant PW.1 is examined. Ext. P1 to P5 are marked. For the opp.party DW.1 is examined. Ext. D1 toD3 are marked. POINTS: Policy in this case is admitted. There is no dispute that the complainant had undergone surgery for inguinal Hernia at Upasana Hospital on 5.3.08. The submission of claim by the complainant to the opp.parties is also not in dispute. The contention of the opp.parties is that at the time of inception of policy the complainant was having pre-existing disease which he has suppressed and therefore under clause 4 [1] of the policy they are not bound to pay the complainant the amount as per the policy. As a matter of fact the opp.parties are relying on Ext.D2 investigation report and D3 a statement alleges to have been furnished by the wife of the complainant for the repudiation of the claim . These 2 documents were proved through an employee of the opp.parties. Neither person who conducted the investigation nor the wife of the complainant were examined and therefore no credibility can be attributed. Ext.D2 and D3 it is also pertinent to point out that the doctor who had treated the complainant was not examined nor questioned by the investigator and no satisfactory explanation is forthcoming for not doing so. It is worth pointing out in this context that Ext.P3 certificate shows that the complainant was suffering from the illness of inguinal hernia for the past 1 year. DW.1 has admitted in cross examination that the repudiation of the claim was only on the basis of Ext. D2 and D3 no medical evidence is adduced by the opp.parties in this case. In the absence of any medical evidence to show that the complainant was suffering from pre-existing illness the evidence of DW.1 and Ext. D2 and D3 cannot be safely relied on to come to a conclusion that the complainant had pre-existing inguinal ernia at the time of taking the policy. In these circumstances we are of the view that the repudiation of the claim is not proper and that there is deficiency in service on the part of the opp.party . Point found accordingly. In the result the complaint is allowed, directing the opp.party to pay the complainant Rs.15,450/- with interest at 12 % per annum from 17.6.2008 till realization. The opp.party are also directed to pay Rs.2,000/- towards compensation and costs. Dated this the 30th day of April, 2010. . I N D E X List of witnesses for the complainant PW.1.- Madhavan Pillai List of documents for the complainant P1. – Policy P2. – Repudiation letter P3. – Medical certificate P4. – Bills P5. – Mathrubhomi paper cutting List of witnesses for the opp.party DW.1. – R. Ashokan List of documents for the opp.party D1. – Policy and conditions D2. – Statement D3. – Investigation report. | 
