By Sri. Chandran Alachery, Member:

The complaint is filed under section 12 of the Consumer Protection Act for an order directing the Opposite Parties to pay Rs.22,500/- with interest at the rate of 18% per annum from 22.02.2013 till realization towards treatment expenses and also directing the Opposite parties to pay Rs.5,000/- as compensation and Rs.1,000/- as cost of the proceedings.

2. Complaint in brief:- The Complainant is senior citizen and 1^st Opposite Party advised to take a health insurance policy from the Opposite Party's company and as per advice, the Complainant joined in to a health insurance policy with Opposite parties on 31.03.2012 by paying a premium of Rs.4,908/-. The policy period is 31.03.2012 to 30.03.2013. The complainant renewed the policy for the period 31.03.2013 to 30.03.2014 by paying the same premium. The Complainant on 04.02.2013 consulted at MIMS Hospital Kozhikode and on the next day, the stomach pain increased and then the Complainant admitted in Leo Hospital Kalpetta for 5 days. After that as instructed by the Doctor, the Complainant admitted at Kozhikode MIMS Hospital for 10 days for treatment of diabetic disease. The complainant spent Rs.22,500/- for medical expenses for medicine, X' ray, by-standers expenses and other laboratorial experiments. At the time of admission at MIMS Kozhikode, the Complainant informed the 2^nd Opposite Party about admission in toll free number. After discharge, the Complainant filled up claim form and gave to 1^st Opposite party. The 2^nd Opposite party repudiated the claim and send letter to the Complainant on 28.05.2011. The reason stated is that the Complainant was suffering from diabetic disease since 4 years. The act of Opposite parties are deficiency of service. Aggrieved by this the complaint is filed.

3. On receipt of complaint, notice were issued to Opposite Parties and Opposite parties appeared before the Forum and filed version. In the version of Opposite Parties, the Opposite Parties contended that the proposal form is the basis and integral part of insurance contract. The policy is issued strictly on the basis of terms and conditions. The complainant is bound to give proper information regarding health status. If the information given is wrong and untrue, no liability to the insurance company. The discharge summary shows the past history of patient that the patient is suffering from diabetics for 4 years on treatment dysuria and increased urinary frequency. The patient had taken treatment for it. The present ailment does not require Hospitalized treatment as inpatient. So there is suppression of material facts which makes the contract void abinito.

4. On perusal of complaint, version and documents, the Forum raised the following

points for consideration.

1. Whether there is deficiency of service from the part of Opposite Parties.

2. Relief and cost.

5. Point No.1:- The Complainant filed proof affidavit and is examined as PW1 and documents are marked as Exts.A1 to A3 series. Opposite parties also filed proof affidavit and 1^st Opposite party is examined as OPW1 and Ext.B1 to B13 is marked. The reason for repudiation of claim is that the Doctor in discharge summary stated in the history column that the complainant is a known diabetic for 4 year on treatment from outside. The Complainant also given history of dysuria and increased urinary frequency. So according to the Opposite Parties there is suppression of material facts. Another contention taken by the Opposite parties is that the treatment for the present ailment requires no admission an in patient. In the cross examination of PW1, PW1 stated that he was admitted as inpatient in MIMS, Kozhikode as per the direction of doctor. More over, PW1 deposed that he had sugar from 2 years back. On perusal , the Forum found that admission is necessary or not is to be decided by the doctor. Here, the Doctor who admitted the complainant in the Hospital for treatment. In the discharge summary (Ext.B5), the Doctor stated the history of the patient that the patient is suffering from sugar 4 years back on treatment from outside. On perusal the Forum found that the doctor not referred any document or previous treatment history before making such a findings. Admittedly the policy is a senior citizen policy and hyper technicalities can be avoided. The claim amount is only Rs.22,500/-. The Forum is of the opinion that the repudiation of claim of Complainant is a deficiency of service from the part of Opposite Parties. Point No.1 is found accordingly.

6. Point No.2:- Since point No.1 is found in favour of Complainant, the Complainant is entitled to get cost and compensation.

In the result, the complaint is partly allowed and the Opposite Parties are directed to pay Rs.22,500/- (Rupees Twenty Two thousand Five hundred ) only to the Complainant towards treatment expenses with 12% interest from the date of filing of this petition till payment. The Opposite parties are also directed to pay Rs.1,000/- as cost and Rs.1,000/- as compensation to the Complainant. The Opposite parties shall comply the order 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 9^th day of July 2015.

Date of Filing:09.12.2013

PRESIDENT :Sd/-

MEMBER :Sd/-

MEMBER :Sd/-

/True Copy/

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witness for the complainant:

PW1. Aboobakkar. Complainant.

Witness for the Opposite Parties:

Nil.

Exhibits for the complainant:

A1. (2 numbers) Senior Citizens Red Carpet Insurance Policy Schedule.

A2 (29 numbers) Bills.

A3 (7 numbers) Bill

Exhibits for the opposite Parties.

B1. Authorisation Letter. dt:22.05.2015

B2. Senior Citizens Red Carpet Insurance Policy.

B3. Senior Citizens Red Carpet Insurance Policy – Schedule.

B4. Senior Citizens Red Carpet Insurance Policy – Proposal.

B5. Copy of Discharge Summary.

B6. Claim Form for Medical Insurance. dt:11.02.2013.

B7. Copy of Letter. dt:09.04.2013.

B8. Copy of Discharge Summary.

B9. Claim Form For Medical Insurance.

B10. Copy of Letter. dt:24.05.2013.

B11. Copy of Discharge Summary.

B12. Claim Form For Medical Insurance. dt:11.04.2013.

B13. Copy of Letter. dt:28.05.2013.