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.50,000/- to the Complainant as the medical expenses spend by the Complainant and also to pay Rs.50,000/- as compensation and cost of the proceedings.

2. Complaint in brief:- The Complainant joined in a mediclaim insurance policy with Opposite party and the period of coverage is from 07.09.2015 to 06.09.2016. The Complainant on 29.12.2015 admitted in St. Joseph's Mission Hospital Mananathavady for the treatment of Osteoarthritis /Anemia/ stool OB. The Complainant was treated there till 01.01.2016. After treatment, the Complainant submitted all treatment documents to the Opposite parties and claimed compensation. The claim is rejected by the Opposite parties without any legal basis stating that “ the claim falls under the 2^nd year exclusion clause of the given mediclaim policy”. The act of Opposite parties are deficiency of service from their part . Hence the complaint is filed for getting compensation.

3. On receipt of complaint, notices were issued to Opposite parties and Opposite Parties appeared before the Forum and filed versions. In the version of Opposite Parties, Opposite parties admitted that the Complainant had taken the policy named Senior Citizens Red Carpet Insurance Policy from the Opposite Parties for the period from 30.08.2014 to 29.08.2015. The sum assured is Rs.1,00,000/- and renewed for a period from 07.09.2015 to 06.09.2016. Terms and conditions are supplied. Medical examination is not required and insured must be of above 60 years of age. As per policy only those pre-existing disease which are specifically declared by the insured in the proposal form are covered under the policy. The Opposite Party to provide coverage with suitable co-payment ie 50% of each and every claim arising out of all pre-existing disease as defined and 30% in case of all other claims which are to be borne by the insured. The proposal form is the basis of insurance contract and any particulars stated in the proposal form are found incorrect, the insurance company would incur 'no liability' under the policy. The treatment records reveals that the patient has history of chronic obstructive pulmonary disease and osteoarthritis since 2010 and also had history of lip surgery in July 2014 and pelvis organ prolapse since April 2012. The policy commenced only from 30.08.2014. The Complainant has not furnished any details regarding the health conditions in the proposal form and it amounts to suppression of material facts which makes the contract void abinitio. Hence the claim is repudiated as per letter dated 05.04.2016.

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 A5. The Opposite party also filed proof affidavit and the Opposite party is examined as OPW1 and documents are marked as Exts.B1 to B11. Ext.A1 is the brochure, stating the details of policy, Ext.A2 is the discharge summary, Ext.A3 is the medical bill, Ext.A4 and A5 is the lab reports, Ext.B1 is the schedule of policy, Ext.B2 is the copy of proposal form, Ext.B3 is the denial of pre-authorisation for cashless treatment letter, Ext.B4 is the request for cashless benefit, Ext.B5 is the claim form, Ext.B6 is the copy of Discharge summary, Ext.B7 is the copy of case history, Ext.B8 is the repudiation letter, Ext.B9 is the copy of application to return the documents, Ext.B10 is the letter showing that the documents are send back, Ext.B11 is the authorisation letter. Admittedly, the policy is a senior citizens Red Carpet policy where in no medical examination is required. The Complainant is aged 75 years. The Complainant had taken the policy through agent of Opposite Parties and normally the agent is filling the proposal form and getting signature of the Complainant. In the Ext.B2 proposal form no critical illness or major disease are reported. The diagnosed illness is osteoarthritis which is common especially to an aged women. An aged person may not be knowing the gravity of illness and it is the insurer to make sure that no such disease exists at the time of joining the policy. The Opposite parties should expect such disease in an aged person and should conduct medical examination before issuing the policy. After getting premium amount and blindly issuing policy when a claim arises, repudiating the claim with untenable reasons cannot be justified. More over, under humanitarian consideration also in senior citizen policy, the Opposite Party should settle the claim. So the Forum is of the opinion that repudiation of claim is a clear deficiency of service from the part of Opposite Parties. The Complainant produced a bill for Rs.5,971.57/- towards medical expenses. No other documents produced to prove that the Complainant had incured Rs.50,000/- as medical expenses. Hence the Complainant is entitled only Rs.5,971.57/- towards medical expenses. 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 to Opposite parties are directed to pay Rs.5,971.57/- (Rupees Five thousand Nine hundred Seventy One and Fifty Seven Paise towards medical expenses to the Complainant. The Opposite Parties are also directed to pay Rs.2,000/- (Rupees Two thousand) only as compensation and Rs.2,000/- (Rupees Two thousand) only as cost of the proceedings. The Opposite parties shall pay the amount within 30 days from the date of receipt of this order failing which the Complainant is entitled to get 12% interest for the medical expenses and compensation amount only.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Forum on this the 21^st day of February 2017.

Date of Filing:29.07.2016.

PRESIDENT : Sd/-

MEMBER : Sd/-

MEMBER : Sd/-

/True Copy/

PRESIDENT, CDRF, WAYANAD.

APPENDIX.

Witnesses for the complainant:

Nil.

Witness for the Opposite Parties :

OPW1. Balu.M. Executive Officer, Star Health Insurance,

Thiruvananthapuram.

Exhibits for the complainant:

A1. Brochure.

A2. Discharge Summary.

A3. Medical Bill. dt:01.01.2016.

A4. Laboratory Test Report.

A5. Laboratory Test Report.

Exhibits for the opposite Party:

B1. Copy of Policy Schedule.

B2. Copy of Proposal form.

B3. Copy of Denial of Pre-Authorization for Cashless treatment letter. dt:01.01.2016.

B4. Copy of Request for cashless Hospitalisation for Medical Insurance policy.

B5. Copy of Claim Form.

B6. Copy of Discharge Summary.

B7. Copy of Case History.

B8. Copy of Repudiation of Claim. dt:05.04.2016.

B9. Copy of Letter.

B10. Copy of Letter. dt:18.06.2016.

B11. Authorisation Letter. dt:13.12.2016.