<br /> <br /> <br /> By ADV. RAVI SUSHA, MEMBER.<br /> <br /> The complainant has filed this complaint for getting the claim amount Rs.20,000/- and for compensation and cost. The averments in the complaint is briefly summarized as follows:<br /> <br /> The complainant had taken an individual medical claim policy from the 2nd opp.party earlier vide policy No.889/2000 for a period from 28.3.2000 to 27.3.2001 and renewed the same for 1 year from 28.3.2001 to 27.3.2002 vide policy No.986/2001.. As per the terms and conditions stated in the policy, company is liable to pay an amount not exceeding Rs.20,000/- to the insured person as medical expenses incurred due to disease or illness or bodily injury during the period of insurance. The complainant was admitted to Amrutha Institute of Medical Sciences and Research Centre at Kochi and underwent coronary Baloon Angioplasty on 20.6.2001. The complainant submitted medical bills and all other records before the opp.party along with the application for medical reimbursement amount. But on receipt of this application the opp.party sent a letter to the complainant stating that the company is not liable for payment because the disease, is pre-existent one and the complainant is aware of the existence of the disease. The complainant was not aware of the existence or symptoms of the disease at the time of buying the individual mediclaim policy. Hence the complainant approached this Forum for relief.<br /> <br /> The opp.parties filed version contending, interalia, that the complaint is not maintainable either in law or on facts. The definition complaint, complainant, Consumer Dispute serve as defined in section 2[1] of the Consumer Protection Act do not cover the claim made out in the complaint. The opp.party had issued mediclaim policy to the complainant fully trusting on the declaration given in the proposal form submitted by him. The complainant had deliberately given false declaration in the proposal form about his medical history and the existing heart illness and diseases he was suffering at the time of proposing for the insurance. The complainant has given incorrect statements, answers or particulars for the questionnaires given in the proposal form. The complainant in this case was under going treatment for his illness associated with heart from Dr. Sreedharan Potti, Cardiologist, Trivandrum, right from the year 1989 onwards. The complainant had visited G.G. Hospital, Trivandrum on 29.,3.2001 with the complaint of discomfort chest since fifteen days from the above facts and evidence that the complainant was suffering from chest problem and was undergoing treatment for the same at the time of submitting the proposal form on 27.3.2001. The complainant in this case has deliberately suppressed the material fact regarding the heart disease/illness existing with him at the time of proposing for the insurance. According to the doctor the complainant/patient could have been aware of the existence of the illness one month prior to the 1st consultation ie. From 10.3.2001 onwards. But the complainant deliberately suppressed the above fact in the proposal form submitted by him and fraudulently obtained the insurance policy from this opp.party with a view to get the expenses likely to incurred for treatment related with his heart disease. As per exclusion clause NO.4.1 of the insurance policy, the company shall not be liable to make any payment under the policy in respect of any expenses incurred by the insured person in respect of such diseases which have been existence at the time of proposing the insurance. The opp.party has repudiated the claim of the complainant on genuine and valid grounds and as such lno deficiency in service is attributable against the opp.party in this case. The complainant has no cause of action against the opp.party since there is no deficiency in service on the part of the opp.party. Hence the opp.party prays to dismiss the complaint.<br /> <br /> <br /> <br /> Points that would arise for consideration are:<br /> <br /> [1] Whether there is deficiency in service on the part of the opp.parties<br /> [2] Reliefs and costs.<br /> <br /> <br /> For the complainant PW.1 is examined. Ext. P1. to P3 are marked.<br /> <br /> For the opp.party DW.1 is examined. Ext. D1. toD6 are marked.<br /> <br /> <br /> Points 1 & 2:<br /> <br /> The complainant had taken an individual medi claim policy from the opp.party for a period from 28.3.2000 to 27.3.2001 and renewed the same for 1 year from 28.3.2001 to 27.3.2002. The complainant had underwent coronary Baloon Augioplasty on 20.6.2001 at Amrutha Institute of Medical Sciences and Research Centre at Kochi. Complainant claimed for the claim amount. But the opp.party repudiated the claim on the ground that the disease is pre-existing one and the complainant is aware of the existence of the disease.<br /> <br /> Opp.parties contended that the insured had given false declaration in the proposal form about his medical history and the existing heart illness and diseases he was suffering at the time of proposing for the insurance. For proving the pre-existence of disease, the opp.party produced Ext. D3, D4 and D5. All these documents are marked as subject to proof. Opp.party failed to prove these document without producing the originals of Ext.D3, and D4 or filing any affidavit of the doctors who have made the said observati9on with relating to Ext. D5 the investigator has not been examined. The opp.parties had not shown any evidence that the insured has aware of the disease prior to the date of proposal. Merely on the basis of an observation made by a doctor without filing any affidavit of the doctor, who has made the said observation, the claim was repudiated on the ground of suppression of disclosure of disease at the time of taking the policy whether the insured had prior knowledge of his condition before taking the proposal form and whether he was under treatment has not been established by the opp.parties. Simple allegations made by the petitioner that the insured was fully aware of the existence of the heart ailment before renewing the policy would not be sufficient.<br /> <br /> Therefore in our opinion, the insurer are under an obligation to pay the complainant Rs.20,000/- as the claim amount under the Medi claim policy.<br /> <br /> In the result, the complaint is allowed. The opp.parties are directed to pay Rs.20,000/- as the claim amount to the complainant. The opp.parties are also directed to pay Rs.2000/- as compensation and 1000/- as cost to the proceeding. The order is to be complied with within one month from the date of receipt of the order.<br /> <br /> <br /> <br /> <br /> Dated this the 26th day of Aapril, 2008.<br /> <br /> <br /> <br /> <br /> I n d e x<br /> <br /> List of witnesses for the complainant <br /> PW.1. – Gopinathan<br /> <br /> List of documents for the complainant<br /> P1. – Surgery Bill from AIMS<br /> P2. – Policy certificate<br /> P3. – Repudiation Letter dated 26.4.2002<br /> List of witnesses for the opp.parties<br /> DW.1. – R. Asok Kumar.<br /> <br /> List of documents for the opp.parties<br /> D1. – Proposal form.<br /> D2. – Policy with conditions<br /> D3. – Discharge summary.<br /> D4. – Treatment summary<br /> D5. –Investigator’s report<br /> D6. – Repudiation letter.<br />