By. Smt. Renimol Mathew, Member:

The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to get the claim amount with cost and compensation.

2. Brief of the complaint:- The complainant taken a Family Health Optima New policy vide No.P/181314/01/2013/003765 from the opposite parties. The period of coverage is from 26.11.2012 to 25.11.2013. The complainant is treated at the WIMS sub centre, Kamblakkad for pain on left shoulder and chest on 30.09.2013. Then on 02.10.2013 he consulted Doctor at Leo Hospital, Kalpetta. Thereafter on 09.10.2013 to 12.10.2013 complainant admitted and treated at MIMS, Calicut. From there the Doctor diagnosed as mild disc bulge at C3-C7 intravertibral disc (Cervical Radiculopathy). Various procedure were undergone including MRI scanning. The complainant was discharged on 12.10.2013. Altogether the complainant had spent a sum of Rs.13,807/- at the MIMS Hospital itself. Thereafter complainant submitted claim form to the opposite party. On 07.11.2013 opposite party repudiated the claim stating that “treatment for the above decease is during the 1^st year of the policy and exclusion clause No.3 of the policy, company is not liable to make payments”. The complainant alleges that this is deficiency of service from the part of opposite parties. Hence filed this complaint to get reimbursement of the bill amount with cost and compensation.

3. Notices served to opposite parties they appeared and filed version. In the version they admitted the policy. They stated that there is no deficiency of services from the part of them. They also admitted the receipt of the claim form and repudiation of the claim. It is submitted that Exclusion clause No.3 of the policy states that “During the First Two Years of continuous operation of the Insurance cover, the expenses on treatment of Cataract, Hyseterectorny for Menorrhagia or Fibromyoma, treatment for Knee and/ or joint (other than caused by an accident), Prolapse of Intervertibral Disc (other than caused by an accident) , Varicose veins and Varicose ulcers. If these are Pre-Existing at the time of proposal they will be covered subject to exclusion No.1 above". So as the treatment taken by the complainant was during the first two year of the policy the Opposite parties repudiated his claim under the said clause of the policy. The complainant has never informed the Opposite parties regarding his prior treatment at WIMS Sub Centre at Kambalakkad on 30.09.2013 and at Leo Hospital, Kalpetta on 02.10.2013 to this Opposite Parties. Such a story is narrated by the complainant for the first time in his complaint before this Honorable Forum. Even the above treatments was within the first two year of the inception of the policy, it too comes under the clause No.3 of the exclusions of the policy. Moreover the complainant had admitted that he had taken treatment for Cervical disc bulge at C3-C7 intervertebral disc.

4. On perusal of complaint, version and documents the Forum raised the following points for consideration:-

1. Whether there is any deficiency of service from the part of opposite parties?

2. Relief and cost.

5. PointNo.1:- Complainant filed affidavit and examined as PW1 and Ext.A1 to
A4 were marked. Ext.A1 is the Insurance Policy and Ext.A2 is the copy of claim form. Ext.A3 is the Repudiation letter dated 07.11.2013. Ext.A4 is the copy of medical bills. Opposite party filed affidavit and examined as OPW1, Ext.B1 to B5 were marked. On going through the records and submissions the Forum found that complainant admitted and treated at MIMS Hospital, Calicut. Opposite parties admitted the policy. But claim of the complainant is repudiated as per the clause 3 of the exceptions of the policy conditions. The repudiation of the complainant's claim in accordance with the terms and conditions of the policy. Hence the complainant is not entitled to get the entire claim amount as alleged in the complaint. The complainant alleged that he is not aware of the conditions of the policy, the agent of the company not disclosed about the conditions and exceptions of the policy. Again he argued that he had not received the conditions and exceptions along with the policy. But agent is not arrayed as a party in this case to tell the truth. But on humanitarian ground this Forum opine that the complainant is entitled for half of the claim amount with compensation. The Point No.1 is found accordingly.

6. Point No.2:- Since the Point No.1 is found against the opposite parties, they are liable to pay the half of the claim amount as compensation.

In the result, the complaint is partly allowed and the opposite parties are directed to pay Rs.6,000/- (Rupees Six Thousand) half of the claim amount as compensation. No order as to costs. This Order must be complied by the opposite parties within 30 days from the date of receipt of this Order.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 30^th day of June 2015.

Date of Filing:01.01.2014 PRESIDENT :Sd/- MEMBER :Sd/-

MEMBER :Sd/-

/True Copy/

Sd/-

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witness for the complainant:-

PW1. Abdul Rahman. Complainant.

Witness for the Opposite Parties:-

OPW1. Manu Mohan. Executive Officer, Claims Star Health.

Exhibits for the complainant:

A1. Family Health Optima Insurance Policy schedule.

A2. Copy of Claim form for medical Insurance.

A3. Claim Repudiation letter. Dt:07.11.2013.

A4. Discharge Bill.

Exhibits for the opposite parties:-

B1. Family Health Optima Insurance Policy Conditions.

B2. Discharge Summary.

B3. MRI Report. Dt:10.10.2013.

B4. Claim form for medical Insurance.

B5. Repudiation letter. Dt:08.11.2013.

Sd/-

PRESIDENT, CDRF, WAYANAD.

a/-