By ADV. RAVI SUSHA, MEMBER.<br /> <br /> The complaint is filed by the complainant to get the claim amount with 12% interest and other reliefs.<br /> <br /> The averments in the complaint can be briefly summarized as follows:<br /> The complainant is a Policy holder of the opp.parties Pravasi Suraksha Kudumba Arogya Policy Scheme as Policy No.1999/471/760505/82250[760901] for the period covering from 4.8.99 to 3.8.2004. At the time of joining the scheme the complainant was fee from all diseases. The scheme was for medical reimbursement of the expenses incurred by the insured for the medical treatment undergone by him for the insured period. During the last month of the year 2001 he was certain difficulty in speaking and plain in right and left shoulder and also in legs. He was admitted and treated at Vijaya Hospital, Kottarakkara and referred to Sree Chitra Hospital, Thiruvananthapuram and they diagnosed his disease as Motor Neuron disease Amiotro Hiclteral Sclerosis and they started the treatment. The complainant filed his claim application along with all relevant records before the 2nd opp.party and the claim was settled by the 2nd opp.party. The complainant was again admitted and treated at Amirtha Alyurveda Hospital, T.B.Jn, Kottarakkara from 30.1.2004 to 29.2.2004. The complainant filed this application before the 2nd opp.party and 2nd opp.party rejected the claim on the ground that the disease was pre-existing one. The complainant was not suppressing any material facts from the 2nd opp.party before joining the scheme and at the time of joining the scheme and he was not suffering from the alleged disease. Hence filed this complaint for getting the claim amount.<br /> The opp.parties filed version contending inter alia ,the complaint is not maintainable eithe3r in law or on facts. The opp.party party had issued a Pravasi Surakasha Kudumba Arogya Policy Scheme in favour of the complainant as stated in the complaint. The statement in the complaint that the complainant was free from at the time of joining the scheme, is false and hence denied. The medical record of the Medical Institution where treatment was taken proves that the present complaints or its symptoms were pre-existing as on 4.8.1999. The benefits arising under the policy were strictly as per the terms and conditions therein. As per expert opinion given by the Amrutha Ayurveda Hospiktal, Kottarakkara, the present complaints or symptoms would have been pre-existing as on 4.8.1999, ie. Inception of the policy. Hence the claim was repudiated for valid reasons. There has been no deficiency of service on the part of the opp.parties. The complainant is not entitled for any of the reliefs prayed for. The complaint is only to be dismissed with costs.<br /> <br /> <br /> Based on the contentions the following points 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 /> For the complainant PW.1 is examined. Ext.P1 to P6 are marked.<br /> <br /> For the opp.party DW.1 is examined. Exts. D1 to D3 are marked.<br /> <br /> Points 1 and 2<br /> <br /> It is not disputed that the complainant has taken Ext.D1 policy and that the policy was subsisting when the complainant had undergone treatment from 30..1.2004 to 29.2.2004 at the Amirtha Ayurveda Hospital, T.B. Jn. Kottarakkara. The complainant submitted claim petition which was repudiated by the opp.party as per Ext.P2 on the ground that the illness for which the complainant had undergone treatment is a pre-existing one which comes within the exclusion clause No.1 of Ext. D2 policy condition.<br /> <br /> Now the question is whether the illness for which the complainant had undergone treatment is a pre-existing one or not. The allegation of the opp.party is that the medical records of the medical institution where treatment was taken on proves that the disease were pre-existing as on the inception of the policy and it comes under the exclusion clause No.1 of Ext.D2. But no effort was made by the opp.party to prove the above said allegation. The opp.party has not produced the treatment certificate from the Amritha Ayurveda Hospital, Kottarakkara for proving their allegation. As a matter of fact DW.1 has not produced any material worth believable to show that the present complaints is a pre-existing one from the date of Ext.D1. There is only a vague statement that the disease is a pre-existing one. In the absence of any material mere allegation put forward by the opp.party cannot be accepted. Hence repudiation of claim on the basis of exclusion clause No.1 in Ext.D2 is not applicable be cause it is not proved by the opp.party on the basis of material facts relating to the complainant’s disease. There is deficiency in service on the part of the opp.party.<br /> In the result the complaint is allowed. The opp.parties are directed to give Rs.16,400/- with 9% interest to the complainant as the treatment expense of the complainant in Amritha Ayurveda Hospital, Kottarakkara. The opp.parties are also directed to pay Rs.10,000/- as compensation for deficiency in service on the part of the opp.party. The order is to be complied with within one month from the date of receipt of the order.<br /> <br /> Dated this the 30th day of June, 2008.<br /> <br /> <br /> <br /> I N D E X<br /> <br /> <br /> List of witnesses for the complainant<br /> PW.1. – Vijayalekshmi<br /> <br /> List of documents for the complainant<br /> P1. – Copy of policy certificate.<br /> P2. – Repudiation letter <br /> P3. – Copy of Bills<br /> P4. – Certificate from the Sreechithra Hospital, Thiruvananthapuram.<br /> P5. – Certificate and bills<br /> P6. – Settlement bill<br /> <br /> List of witnesses for the opp.parties<br /> DW.1. – K.R. Lekshmi Narayanan<br /> <br /> List of documents for the opp.parties<br /> D1. – Policy paper<br /> D2. – Terms and conditions<br /> D3. – Letter sent by New India Assurance co. dated 13.10.2004.<br /> <br /> <br />