By Smt. C.S. Sulekha Beevi, President,<br /> <br /> 1. Facts in brief:-<br /> First complainant availed a mediclaim policy with opposite party in year 2001. His wife who is the second complainant and his son were also beneficiaries under the policy. First complainant died pending litigation. Second complainant, suffered severe pain to her hip and legs due to a fall. She was not able to walk properly and consulted doctors of Moulana Hospital, Perintalmanna. She was advised to take Ayurvedic treatment, and was treated as inpatient from 20-12-01 to 03-01-02 at Amrutham Ayurvedic Hospital, Perintalmanna. After treatment her illness subsided and she preferred a claim to opposite party under the policy. Opposite party repudiated the claim. Meanwhile the policy expired and complainant requested to renew the policy. His application for renewal was refused. Hence this complaint claiming Rs.6,000/- as benefits to second complainant under the policy, and for Rs.5,000/- towards deficiency in service.<br /> 2. Opposite party filed version admitting the mediclaim policy for the period 17-01-2001 to 16-01-2002 in favour of complainant and their son. It is submitted that the claim was repudiated because complainant failed to submit relevant documents and necessary details for processing the claim. That several discrepancies were seen in the documents submitted. Even after repeated letters requesting the complainant to furnish necessary details complainant failed to comply such request. Hence opposite party was unable to settle the claim. The request for renewal of policy was not refused in total. That complainants were int eh habit of repeatedly preferring claims and these claims were settled by opposite party as far as possible. The policy was renewed for the second time. That opposite party refused to renew the policy for the third period upon the same premium due to the adverse claim ratio. Opposite party had offered to renew the policy on payment of renewal premium of Rs.5,000/-. Complainant failed to remit this renewal premium and hence policy was not renewed. There is no deficiency in service and complaint is liable to be dismissed.<br /> 3. Evidence consists of affidavits filed by complainant and opposite party. Exts. A1 to A3 marked on the side of complainant. Exts.B1 to B21 marked on behalf of opposite party. Either side has not adduced any oral evidence.<br /> <br /> 4. Points for consideration:-<br /> (i) whether opposite party is deficient in service?<br /> (ii) If so reliefs and costs.<br /> 5. Point (i):-<br /> The grievance of the complainant is two fold. Firstly, that opposite party repudiated the claim of benefits under mediclaim policy. Secondly, that opposite party refused to renew the said policy. It is the say of second complainant that due to fall she sustained severe pain on her hip and legs. On consulting doctors of Moulana Hospital, she was advised to take Ayurvedic treatment. She was admitted as inpatient in Amruthum Ayurvedic Hospital, Perintalmanna from 20-12-2001 to 03-01-02(14 days). The claim preferred before opposite party was repudiated. The complaint is resisted by opposite party contending that the claim was repudiated because complainant failed to produce relevant documents and necessary details for processing the claim. The documents that were submitted by complainant while lodging the claim are produced by opposite party. Counsel for opposite party tried to draw our attention to certain facts traunt in the claim form, medical report and discharge card which are Ext.B3, B4 and B5 respectively.<br /> 6. The claim form is dated nil and it was received by opposite party on 09-01-2002. Column 4 in Ext.B3 pertains to the query regarding nature of disease/illness contracted or injury suffered. Complainant has answered this column as - “Kateegraham due to fall”. Column 5 pertains to the date of injury sustained or disease/illness first detected. This column is unanswered by complainant. Column 8 pertains to the query of date of commencement of treatment, date of completion of treatment, name and address of medical practitioner. The These details are again unanswered and left blank by complainant. In Ext.B4 column 6 pertains to history of illness. The query in column 6(a) is, “According to you, how long the injured person would have been suffering from illness?” This column is left blank. In column 8 the query regarding the details of diagnostic tests carried out prior to hospitalisation is answered, as “Diagnostic tests had been taken prior to the hospitalisation”. The details of the diagnostic tests prior to hospitalisation are not stated. Relevant documents are also not furnished. In Ext.B5, discharge card, the diagnosis noted is “Kateegraham”. But the cause of illness or history of illness is not stated. Something is written against the diagnosis which has been erased by correction fluid.<br /> 7. It was submitted on behalf of opposite party that on finding these discrepencies opposite party requested complainant to furnish details of ailment, treatment and bills. Ext.B6 and B9 are the letters issued by opposite party in this regard. Since the complainant failed to produce further documents the claim was later repudiated. Complainant has stated that some of the documents and bills were lost from his possession. We have given careful consideration of the respective contentions of parties. It is seen that even the complaint is silent as to these details requested by opposite party. The details of ailment and treatment is necessary for opposite party to ascertain whether disease was pre existing or not. Opposite party has to verify whether disease and treatment comes within the exclusions. No shred of evidence is tendered by complainant to prove the cause of injury and the diagnostic tests done prior to inpatient treatment. In our view, in such circumstances, opposite party is justified in raising reasonable doubt regarding the genuineness of claim. Before repudiation complainant was given sufficient opportunity to furnish relevant documents. Admittedly complainant has availed benefits under this policy prior to this claim as well as after this claim. All these claims were settled and paid by opposite party. So complainant is sufficiently aware of the documents needed to process the claim. From the materials on record we are able to conclude that due mind has been applied by opposite party before repudiating the claim. We find opposite party was fully justified in repudiating the claim and the non-settlement in the present case cannot be considered to be deficiency in service.<br /> 8. The second point to be considered is whether the refusal to renew the policy would amount to deficiency in service. Ext.B1 policy was issued initially for the period 17-01-2001 to 16-01-2002. It was renewed for a further period from 17-01-02 to 16-01-03. The request for subsequent renewal was refused by opposite party which the complainant contends to be arbitrary. The history of the policy with regard to it's claim settlement is as follows:-<br /> (i) Under the initial policy first complainant had preferred mediclaim reimbursement and the same was settled by payment of Rs.9,315/- on 09-11-2001.<br /> (ii) Under the renewed policy first complainant again preferred a hospital reimbursement claim for Rs.7,060/- and it was paid on 03-9-2002.<br /> (iii) When this present claim was pending and prior to it's repudiation, second complainant preferred a claim under the renewed policy for hospital expenses, for treatment which commenced on 18-5-2002, which is four months after discharge of the treatment pertaining to this complaint. This claim was also settled by payment of Rs.8,160/- on 14-11-2002.<br /> (iv) Complainant had also availed benefits under the householders policy. Two claims dated, 28-9-2001 and 24-11-2001 were paid for Rs.1,590/- and Rs.240/- respectively.<br /> 9. It was submitted on behalf of opposite party that there was no total refusal to renew the policy. Actually opposite party had only refused to renew the policy upon charging the premium previously paid and was willing to renew upon enhanced renewal premium of Rs.5,000/-. Charging of such enhanced renewal premium was necessary due to the adverse claim ratio of the policy. It is evident that the refusal was not a blanket refusal. Opposite party has sufficiently informed the complainant regarding the refusal to renew the policy upon the previous amount of premium. Complainant was not prepared to pay the enhanced premium and therefore the policy was not renewed. The refusal to renew the policy is based upon factors fully relevant and sound reasons. The ground for refusal has been informed to the complainant in detail by Ext.B19 letter. From the above discussions we hold that the refusal to renew the policy in the present case does not amount to deficiency in service. We find opposite party not deficient in service. Point found against complainant.<br /> 10. Point (ii):-<br /> In the light of above discussions this point also found against complainant.<br /> 11. In the result, we dismiss the complaint. We do not make any order as to costs.<br /> <br /> Dated this 6th day of August, 2008.<br /> <br /> <br /> Sd/-<br /> C.S. SULEKHA BEEVI, PRESIDENT<br /> <br /> Sd/-<br /> E. AYISHAKUTTY, MEMBER<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> APPENDIX<br /> <br /> <br /> Witness examined on the side of the complainant : Nil <br /> Documents marked on the side of the complainant : Ext.A1 to A3<br /> Ext.A1 : Photo copy of the request dated, 14-1-03 by first complainant <br /> to opposite party.<br /> Ext.A2 : copy of the details of the bill issued by Dr.P.Krishnadas BAMS., to <br /> 2nd complainant.<br /> Ext.A3 : O.P. Ticket issued from Dr.Krishnadas Clinic & Amruthum to<br /> 2nd complainant.<br /> Witness examined on the side of the opposite parties : Nil<br /> Documents marked on the side of the opposite parties : Ext.B1 to B21<br /> Ext.B1 : Proposal Form for mediclaim insurance policy dated, 17-01-01<br /> by 2nd complainant to opposite party.<br /> Ext.B2 : Mediclaim Insurance Policy No.101003/48/37/11/432/2001 issued<br /> by opposite party to the complainants.<br /> Ext.B3 : Claim Form by 2nd complainant to the opposite party. <br /> Ext.B4 : Medical report from Dr.P.Krishnadas BAMS., to opposite party.<br /> Ext.B5 : Discharge card issued by Dr.P.Krishnadas BAMS., in favour of<br /> 2nd complainant.<br /> Ext.B6 : Letter dated, 20-01-02 by opposite party to 2nd complainant.<br /> Ext.B7 : Cash bill for Rs.6,000/- from Amruthum Ayurvedic Hospital<br /> & Research Centre to 2nd complainant.<br /> Ext.B8 : Details of the bill issued by Dr.P.Krishnadas BAMS., to <br /> 2nd complainant.<br /> Ext.B9 : Letter by opposite party to 2nd complainant.<br /> Ext.B10 : Request dated, 29-5-02 by 2nd complainant to opposite party.<br /> Ext.B11 : Letter dated, 30-5-02 by opposite party to Divisional Office, Manjeri.<br /> Ext.B12 : Claim note dated, 10-6-02 prepared by Divisional Office, Manjeri.<br /> Ext.B13 : Repudiation letter dated, 20-6-02 by opposite party to 2nd complainant.<br /> <br /> Ext.B14 : Letter dated, 25-11-02 by 1st complainant to Regional Officer of<br /> opposite party.<br /> Ext.B15 : Photo copy of the acknowledgement letter dated, 25-11-2002<br /> from Regional Officer of opposite party to 1st complainant.<br /> Ext.B16 : Letter dated, 29-11-02 by opposite party to Grievance Cell,<br /> Regional Office, Kochi.<br /> Ext.B17 : Photo copy of the letter dated, 13-01-03 addressed by Regional Office<br /> of opposite party to 1st complainant.<br /> Ext.B18 : Request dated, 15-1-03 by first complainant to opposite party.<br /> Ext.B19 : Letter dated, 17-01-03 by opposite party to 1st complainant.<br /> Ext.B20 : Request dated, 20-01-03 by 1st complainant to opposite party. <br /> Ext.B21 : Letter dated, 22-01-03 by opposite party to 1st complainant.<br /> <br /> <br /> <br /> Sd/-<br /> C.S. SULEKHA BEEVI, PRESIDENT<br /> <br /> Sd/-<br /> E. AYISHAKUTTY, MEMBER