By Sri. P. Raveendran, Member:-
 

Brief of the complaint:- The Complainant is an individual Mediclaim Policy Holder under Opposite Party vide Policy No. 101601/48/20/00480 covering the period from 27.6.2006 to 26.6.2007. As per the policy his wife Smt. Vrinda Lakshmi was also covered in the policy and a sum of Rs. 1,612/- was paid as the premium of policy. During the validity period of the policy smt. Vrinda Lakshmi was hospitalised at Malabar Institute of Medical Science, Calicut due to Fibroid Uterus/ Tab with BSO. She was admitted there and subjected to Abdominal Hysterectomy and he spent Rs. 29,115/- for the same. Immediately the Complainant submitted all the documents and medical bills for reimbursement to the Opposite Party. But the Opposite Party rejected the claim stating that the above disease was a pre-existing illness. Rejection the claim is gross deficiency of service on the part of Opposite Party. Hence it is prayed to pass an order directing the Opposite Party to pay.

1. A sum of Rs. 29,115/- with 12% interest.

2. A sum of Rs. 10,000/- as compensation.

3. Cost of the complaint etc to the Complainant.

2. Opposite Party appeared and filed version. In the version Opposite Party admitted that Complainant is a policy holder under them and policy issued to the Complainant. Maximum risk coverage per person is Rs.10,000/-. As per the policy the Complainant and his wife Smt. Vrinda Lakshmi were covered. The claim submitted by the Complainant was processed and on verification of documents it is found that the disease was pre-existing. The complainant's wife Smt. Vrinda Lakshmi had multiple fibroid uterus TAH with BSO. The ailment was since 1 ½ years. The policy inception date was 27.6.2006. The patient was admitted on 26.4.2007 and discharged on 05.05.2007. Hence the claim was repudiated as per the pre-existing clause 4.1 of the policy. Hysterectomy fibrmyoma falls under the first year policy extension as per clause 4.3 of the policy. Hence there is no deficiency of service on the Opposite Party. So disallow the the complaint with cost.

3. Considering the complaint and version the following points are to be considered.

1. Is there any deficiency of service on the part of the Opposite Party?

2. Relief and cost.

4. Point No.1:- To prove Complainant's case, Complainant has filed his proof affidavit and Ext.A1 to A3 documents were also marked. In the proof affidavit he stated as stated in the complaint. Ext.A1 is the claim rejection letter issued by the Paramount health Services Private Ltd., by Opposite Party to the Complainant. In the letter it is clearly noted that the matter is closed. Ext.A3 also a rejection letter issued by Paramount Health services Private Ltd to the Complainant. To prove Opposite Party's case chief affidavit of Opposite Party and Exts.B1 to B3 and B2 (a) documents were marked. Exts.X1 and X2 were also marked by the Forum. In the chief affidavit he stated as stated in the version. Ext.B1 is the Mediclaim Proposal copy. Ext.B2 is the policy of the complainant from 27.6.2007 to 26.6.2008. Ext.B2(a) is the copy of the policy of the Complainant from 27.6.2006 to 26.6.2007. Ext.B3 is the photocopy of the admission request note of Vrinda Lakshmi issued by Dr. Geetha V Balan which was marked subject to prove. Ext.X1 is the Mediclaim Insurance Policy Claim form along with all relevant documents produced by Opposite Party as per the direction of this Forum. Ext.X2 is the case sheet of Vrinda Lakshmi produced from Malabar Institute of Medical Science as per the direction of this Forum.

5. On perusing the documents and affidavits produced by both parties the main contention of Opposite Party is that (1) The Complainant's wife Smt. Vrinda Lakshmi had multiple fibroid uterus TAH with BSO and the ailment was since 1 ½ years. (2) Hysterectomy for fibrmyoma falls under the first year policy. No evidence is adduced before this Forum to prove their contention. Whereas on perusing Ext.X1 it is found that Smt. Dr. Geetha V Balan, M.D, DGO who treated Vrinda Lakshmi clearly noted that she would have been suffering from this illness for the last one month. More over in Ext.X2 also it is clearly recorded like this “Relevant past history is recorded Nil”. The policy is from 27.6.2006 to 26.6.2007. As per Ext.X1 first consultation is on 18.4.2007. So there is no evidence before us she is suffering from this disease at the time of taking the policy. The other contention of Opposite Party is hysterectomy for fibrmyoma falls under the first year policy exclusion as per clause 4.3 of the policy. In Ext.X1 nature of disease is noted as multiple fibroids uterus. No evidence before us hysterectomy is for fibrmyoma. Hence rejecting the claim without sufficient reason is deficiency of service on the part of the Opposite Party. In Smt. Hajeef Kumar V/S National Insurance Co. Ltd and Others 2009 (4) CPR Page 36 by allowing the appeal Hon'ble National Commission has held that no material to show that insured was aware of fibroids in her uterus. No evidence to prove that she was aware of disease. Petitioner was entitled to claim under policy. This is a fit case to apply the above decision. Hence point No.1 is decided in favour of the Complainant.

6. Point No.2:- On going through Ext.B2 (a) (Policy) it is clear that as per the policy the Complainant is entitled to get Rs.10,000/- as domiciliary hospitalisation benefit. So he is entitled to get Rs.10,000/- with interest of 10% from the date of filing the complaint till the payment is made. He is also entitled to get Rs.1,000/- as cost of the Complainant. Point No.2 is decided accordingly.

In the result the complaint is partly allowed and the Opposite Party is directed to pay Rs.10,000/- (Rupees Ten thousand only) with 10% interest from the date of filing the complaint till the payment is made and Rs.1,000/- (Rupees One thousand only) as cost of the complaint to the Complainant. The order is to be complied within one month on receipt of this order.

Pronounced in open Forum on this the day of 30^th December 2009.

PRESIDENT: Sd/-

MEMBER- I: Sd/-

MEMBER-II: Sd/-

APPENDIX

Witness for the Complainant.

PW1. M.S. Venkitaswaran. Complainant.

Witness for the Opposite Parties.

OPW1. Vijayan C.K. Manager, United India Insurance Co., Kalpetta.

Exhibits for the the Complainant:

A1. Claim Rejection Letter. dt:10.11.2007.

A2. Claim Repudiation Letter. dt:02.11.2007.

A3. Claim Rejection Letter. dt:25.05.2007.

Exhibits for the Opposite Parties:

B1. Mediclaim Proposal dt:26.6.2006.

B2. The copy of the policy of the complainant from 27.6.2007 to 26.6.2008.

B2(a). The copy of the policy of the Complainant from 27.6.2006 to 26.6.2007.

B3. Admission Request Note.

X1 series. The Mediclaim Insurance Policy Claim Form along with all relevant documents.