Sri. K. Gopalan: President This is a complaint filed under Section 12 of the Consumer Protection Act for an order directing the opposite party to pay Rs 40,000/-as the expenses of her treatment and Rs 30,000/-as compensation for deficiency of service with cost of the proceedings. The case of the complainant in brief are as follows: The complainant is the holder of the Medi Claim Insurance policy. During the continuance of the policy as per the advice of the Ayurvedic Physician the complainant has undergone treatment of Kadeegraham and accordingly the complainant admitted in the Kottakal Aryavydyasala , Ayurvedic Hospital & Research Centre on 17.1.2002. The complainant has been discharged from the hospital on 15.2.2002 with an advice to continue followup medicine with restricted diet and to report the condition periodically. The compllainants case is that she is entitled to get the amount incurred in connection with her treatment. The complainant has paid Rs 30,243.15 towards hospitalization expenses to the Kottakal Aryavydyasala Hospital. The complainant has also spent Rs 9756.85 towards other medical expenses. The complainant alleges that she has submitted claim form and all other documents in original to opposite party on 21.2.2002. The opposite party directed the complainant to furnish certain document and accordingly submitted the documents to opposite party. As per the demand of opposite party and with the consent of the complainant the Doctor who has examined the complainant at Kottakal Aryavydyasala has sent a detailed Medical Report to the opposite party. The opposite party on receiving the medical certificate from the doctor , directed the complainant to be present at the Koyili Hospital, Kannur for medical examination to know about the medical treatment taken by the complainant prior to the hospitalization at Kottakal. Accordingly Doctor at Koyili Hospital examined the complainant and submitted his medical report to the opposite party. Thereafter the opposite party has sent a letter dt. 4.9.2002 requesting the complainant to submit documents pertaining to treatment taken by the complainant prior to her hospitalization at Kottakal. Complainant sent a reply notice on 9.9.2002 stating that she has not undergone any treatment prior to her hospitalization. After receiving the reply opposite party sent a notice dated 16.9.2002 stating that the opposite party is not able to finalize the claim of the complainant without the support of the documents pertaining to the treatment taken by the complainant prior to her hospitalization at Kottakal and so the opposite party has decided to reject the claim. As per the policy opposite party is liable to pay the amount in connection with the hospitalization of the complainant but the opposite party unilaterally denied the claim. Since the complainant is a policy holder she entitled for expenses from the opposite party. The denial is a deliberate act of opposite party which is amounts to deficiency of service. The complainant is a lady having no job or income. Since the opposite party has not paid the amount of expenses the complainant could not repay the borrowed amount which caused a lot of mental agony and hardships to the complainant. Though complainant has approached directly and sent several letters , opposite party has not paid the amount. Hence this complaint. Opposite party filed version denying the material allegations and averments in the complaint. The contentions of the opposite party in brief are as follows. The complainant is the Medi Claim policy holder but denies the liability to pay any amount as compensation to the complainant. The averment in the complaint that she was suffering from back pain etc and she had consulted in Ayurvedic Physician at Kottakal Aryavydyasala, and she was admitted there as an inpatient from 17.1.2002 and was discharged on 15.2.2002 with advice to continue the treatment periodically etc. are vived description tainted with untrue facts. The complainant is suspensing the past history and period of the disease to cheat the opposite party. Complainant contracted the disease prior to the institution of the policy and the alleged expenses incurred was pre-existing to the policy. As per exclusion No.4.0 and 4.1 of the policy, the insurer is not liable to make any payment in respect of any disease those which have been pre-existing to the effective date of insurance. Complication arising from pre-existing disease will be only considered as part of that pre-existing conditions. The complainant failed to furnish documents sufficient enough to consider the claim. Since the complainant willfully suppressed the past history of the disease she is not entitled for any claim as per the policy condition. The averment in the complaint that she had to incur Rs 30,243.15 towards the treatment expenses and Rs 9,756.85 towards other medical expenses are all exaggeration for appropriating unlawful gain. The claim is not sustainable . The opposite party is not liable to pay any amount towards the medi claim and compensation for the alleged deficiency of service. Hence to dismiss the complaint. On the above pleadings the following issues have been taken for consideration. 1. Whether there is any deficiency on the part of the opposite party? 2. Whether the complainant is entitled for the remedy as prayed in the complaint? 3. Relief and cost. ISSUES 1 to 3: The evidence consists of documentary evidence Exts. A1 to A15 marked on the side of complainant and oral testimony of opposite party as DW1 and documentary evidence Exts. B1 to B7 marked on the side of opposite party. Exts. B2 and B3 are series marked as Ext. B2 ( 1 to 5) and Ext.B3( 1 & 2). ISSUE Nos. 1 to 3: The complainant is the Medi claim insurance policy holder . Ext. A1 shows her policy No. as 571100/48/2001 issued on 29.10.2001. The premium certificate prove the policy issued in the name of the complainant for the period 31.10.2001 to 30.10.2002. Ext. A3 is the certificate issued by Dr. E.P.Unnikrishna Varier, Deputy Chief Physician, Aryvydyasala, Kottakal. Ext. A3 certified that Mrs. Sarojini, the complainant has been admitted in Ayurvedic Hospital & Research Centre for the treatment of Kadeegraham( back pain )on 17.1.2002. The certificate was issued on 22.1.2002 stating that she has to stay in the hospital 28 days to complete the course of treatment as per the then schedule. Ext. A4 discharge summary confirms the day of admission on 17.1.2002 and gives the date of discharge on 15.2.2002. It means she had been in hospital for 28 days. Ext. A3, 4 & 11 documents undoubtedly make it clear that she had undergone treatment and completed the course of Kadeegraham under Dr. E.P. Unnikrishna Varier in Ayurvedic Hospital & Research Centre, Kottakal. Ext. A4 also advise to continue the follow up medicines with restricted diet and to report the condition periodically. In answering to the questions in detail in Ext. A6 ,Medical Certificate by Arya vaidyan K.V.R. Varier described the nature of illness and cause for contracting the disease thus: Back pain radiates to legs, more in the right leg, knee joint pain . Numbness of the legs pain in the right scapular region and right hand. Occasional giddiness, palpitation and dyspnoea. And for the question cause for contracting the disease separately answered Nothing relevant. The answer to the 13th question shows that the complainant had been advised to follow up medicines as per the prescription for one month. Hence Ext. A6 undoubtedly make it clear that she was suffering from back pain and underwent treatment from 17.1.2002 to 15.2.2002 in Kottakal Aryavaidyasala. As per the direction by Ext. B2(2) complainant was asked to present at Koyili Hospital, Kannur for the purpose of the Medical Examination, as part of arrangement of investigation. Ayurvedic treatments are not restricted for eligibility to get the claim. In short Exts. A3, A4 & A6 are relevant documents sufficient enough to substantiate the claims of the complainant. The opposite party contended that the diseases for which she had undergone treatment and expenses incurred was preexisting to the insurance policy. Ext. A3 issued by Dr. E.P.Unnikrishna Varier , Aryavaidyan, Deputy Chief Physician , Kottakal certified that the complainant had been admitted in Ayurvedic Hospital & Research Centre for treatment of Kadeegraham on 17.1.2002. It has also stated that she has to stay there 28 days to complete the course of treatment as per the schedule. Ext. A4 discharge summary gives details of treatment. As per Ext. A4 complainant had been admitted on 17.1.2002 and discharged on 15.2.2002. Ext. A4 also shows history of previous illness Nil. It gives the details of course of treatment in the hospital, condition on discharge and advice of discharge. Ext. A4 is undersigned by a well known Dr. K.V.R. Varier. The opposite party argues that the answers given by Kottakal Aryavaidyasala was not genuine since they were colluding with the complainant . This is a contention without any basis and not acceptable. Opposite party was not able to prove otherwise, whatsoever cotended. Opposite party contended that they have taken earnest attempt to settle the case by Ext.B2, 3, 4 & 5. Ext.B2 series are letters to submit document pertaining to the treatments taken prior to the treatment at Kottakal Aryavaidyasala. Complainants specific case is that she had not taken any treatment prior to the hospitalization at Kottakal. Ext.B2(2) is the letter directing the complainant to present at Koyili Hospital, Kannur. As per the direction the complainant reported before Dr. Gangadharan at Koyili Hospital. Ext. B2(3) letter to furnish the document. Complainant earlier submitted to opposite party there was no treatment taken prior to hospitalization at Kottakal. Ext.B2(3) did not say what all documents to be produced. It seems to be an attempt to avoid the complainant from settling the claim. Ext.B2(4) reminding, the conditions no.5.5 and 5.6 of the policy is also a mere attempt to make an impression that earnest attempt is being taken to settle the claim. Ext.B2(5) also remains as a meaningless effort knowing well that the complainant has not been keeping any such documents with her. It is really meant to give a warning that the claim is intended to repudiate, which is clearly a negative approach. Ext. B3(1) was replied by complainant on 9.9.2002. Complainant responded by Ext. B3(2) Ext.A5 is the copy of discharge bill. The original is with the opposite party which has been procured together with the opposite partys document. Ext. A5 discharge bill shows the treatment expenses for the period 17.1.2002 to 15.2.2002 when the complainant underwent treatment at Kottakal Aryavaidyasala. The contention of opposite party that the disease for which she had undergone treatment and expenses incurred was preexisting to the insurance policy is baseless and devoid of any reasoning. Had there been any evidence that the complainant had taken treatment prior to the policy from any hospital the position would have been different one. Opposite party also arguing that as per the policy and its conditions it envisages that the complainant is entitled for the medical benefits only if the complainant undergoes allopathic treatment and not for any other treatment is not supported by any documents. The evidence available on record does not show the expenses incurred for Ayurvedic Treatments are excluded from Medi Claim policy. Ext.A1 Medi Claim policy issued to complainant does not contain any conditions to exclude ayurvedic treatments. Doors of justice cannot be shut to the complainant for technical reasons . Thus in the facts and circumstances , just narrated above, we have no hesitation to hold that the repudiation of claim of complainant on the ground of suppression of material facts is unjustifiable and rejection of claim amounted to deficiency in service on the part of the opposite party. There is no evidence that the complainant has taken treatment prior to the policy from any hospital. Hence complainant is entitled for the claim. Ext. A5 discharge bill reveals that the total expense of Rs 30,243.15 paid in Kottakal Aryavaidyasala for the treatment of complainant for the period 17.1.2002 to 15.2.2002. Hence the opposite party is liable to pay Rs 30,243/- to complainant as claim for the medical expenses incurred by the complainant for her treatment at Kottakal Aryavaidyasala ,Kottakal with an interest @ 10% per annum from the date of order to the realization of the amount . Complainant is also entitled for Rs 1500/-as cost of this proceedings. The issues 1 to 3 are found in favour of the complainant . Order passed accordingly. In the result, the complaint is allowed partly directing the opposite party to pay Rs 30,243/-(Rupees thirty thousand two hundred forty three only) with an interest @ 10% per annum from the date of order to the realization of the amount as medical expenses incurred for the complainant together with Rs 1500/-( Rupees one thousand five hundred only) as cost of this proceedings within one month from the date of receipt of this order failing which the complainant is allowed to execute the order as per the provisions of Consumer Protection Act. Sd/- MEMBER Sd/- MEMBER Sd/- PRESIDENT APPENDIX Exhibits for the complainant A1. Mediclaim insurance policy of the complainant. A2. Receipt dt. 29.10.2001 issued by the opposite party A3. Certificate dt. 22.1.2002 issued by Dr.E.P. Unnikrishna Varier, Kottakal Arya Vaidya Sala. A4. Discharge summary dt. 15.2.2002 issued from Kottakkal Arya Vaidya Sala. A5. Bill dt. 15.2.2002 issued from Kottakkal Arya Vaidya Sala. A6. Attending Doctors report issued by Dr.KVR Varier. A7. Letter dt. 12.6.2002 sent by Dr. KVR Varier to the opposite party A8. Letter dt. 27.5.2002 sent by the opposite party. A9. Letter dt. Nil sent to Kottakkal Arya Vaidya Sala. A10. Letter dt. 7.8.2002 sent by the opposite party. A11. Copy of the letter dt. 12.6.2002 sent by Dr. KVR Varier to the opposite party. A12. Report of Dr. Gangadharan Nair, Koyili Hospital, Kannur. A13. Letter dt. 16.9.2002 sent by the opposite party. A14.Mediclaim insurance policy (revised) of the complainant. A15. Premium certificate of the complainant. Exhibits for the opposite party B1. Mediclaim policy schedule of the complainant. B2 (1 to 5): Letters dt. 4.9.2002, 7.8.2002, 22.4.2002, 28.3.2002, 19.3.2002 sent to the complainant. B3(1 ) : Letter dt. 6.3.2002 sent to the complainant. B3(2) Letter dt. 9.9.2002 sent by the complainant B4. Copy of the letter dt. 2.5.2002 sent by the complainant B5. Letter dt. 25.7.2002 sent by Dr.KVR Varier. B6. Letter dt. 8.7.2002 sent to Dr. KVR Varier. B7. Investigation report of Excel Private Detective Agency. Dt. 16.9.2002. Witness examined for the complainant- Nil Witness examined for the opposite party DW1. T.A. Sankarankutty Forwarded/by order SENIOR SUPERINTENDENT
