ADV. RAVI SUSHA, MEMBER. Complaint for seeking realization of insurance claim, interest, cost etc. The averments in the complaint can be briefly summarized as follows: The complainant is a holder of Medicalim Policy No.760900/3 A/07/11/00000036 valid upto 1.1.2009 issued by the opp.party. The complainant underwent treatment for coronary artery disease in the SUT Hospital, Trivandrum as inpatient from 1.5.08 to 12.5.08. Bill for the medical expense of Rs.150769/- from the Hospital was duly forwarded. But the opp.party has sanctioned Rs.51570/- on ly. So the balance amount of Rs.99019/- was paid by the complainant at the time of discharge. No reason for limiting the claim amount to Rs.51570/- was given. Since the policy cover Rs.1,00,000/- the opp.parties are bound to pay the balance amount of Rs.48250/-. So there is deficiency in service on the part of the opp.parties. There is deficiency in service on the part of the opp.parties. Hence the complaint. The 1st opp.party filed a version contending, interalia, that the complaint is not maintainable either in law or on facts. The opp.party had issued a mediclaim insurance policy to the complainant and his wife for a period commencing from 2.1.2008 to 1.1.2009. The policy was a continuing renewal policy from the year 2003 onwards without any break. The sum insured of the complainant under the immediate previous policy commencing for a period from 2.1.2007 to 1.1.2008 was Rs.45,000/- with a cumulative no claim bonus amount of Rs.4,500/- . While the complainant renewed the policy on 2.1.2008, he has enhanced the sum insured under the policy from 45,000/- to 1,00,000/-. At the time of renewal of the policy the complainant was eligible for the cumulative no claim bonus amount Rs.6,750/- in addition to the existing previous sum insured of Rs.45,000/- . The enhanced sum of Rs.55,000/- given in the policy for the period from 2.1.2008 to 1.1.2009 is a fresh policy, which has shown as separately in the policy schedule itself. The terms and conditions and all other restriction as applicable to a fresh policy will squarely apply to the additional sum insured [enhanced sum insured] as if it is a new policy. The complainant had preferred a claim with this opp.party for the treatment taken by him for his Coronary Artery Disease in SUT Hospital, Trivandrum during his policy period 2.1.2008 to 1.1.2009. As per the claim form submitted by the complainant as well as from the medical records given by the treated doctor, he was suffering from Coronary Artery Disease for which he had taken treatment from the above hospital, As per the discharge summery issued from SUT Hospital produced by the complainant before this opp.party, the previous history about his cardiac disease and the treatment taken by him from elsewhere are very clearly mentioned. Since the enhanced sum insured of Rs.55,000/- during the policy period commencing from 2.1.2008 to 1.1.2009 is a new policy, the same will be considered as if it is a separate policy governing under different terms and conditions. As per clause 6[c] of the nenewal policy condition if the policy is to be renewed for enhanced sum insured, then the restriction as applicable to a fresh policy will apply to additional sum insured as if a separate policy has been issued for the difference. In other words, the enhanced sum insured will not be available for an illness, disease, injury already contracted to the insured under the preceding policy periods. So the complainant was eligible to a maximum compensation amount of Rs.51,750/- only on the claim reported by him as per the terms and conditions of the policy. The claim advanced by the complainant against this opp.party is liable to be dismissed with compensatory cost of this opp.party. There is no deficiency in service on the party of the 1st opp.party. Hence the 1st opp.party prays to dismiss the complaint. Points that would arise for consideration are: 1. Whether there is deficiency in service on the part of the opp.parties 2. Reliefs and costs. For the complainant PW.1 is examined. Ext.P1 to P11 are marked. For the opp.parties Ext. D1 to D5 are marked. POINTS; Complainants’ case is that he is a holder of Medi claim policy valid from 2008-09 issued by the opp.party. He underwent treatment for cononary artery disease from 1.5.08 to12.5.08 at SUT Hospital. He claimed Medical expense of Rs.150765/- But the opp.party sanctioned only Rs.51750/- Hence the complainant filed this complaint for getting the balance claim amount. Opp.parties main contentions are that the complainant was a policy holder with the opp.party from 2003 onwards for a sum of Rs.45,000/- The complainant renewal the policy on 2.1.208 enhanced the sum insured from 45,000/-to 1,00,000/- As per the policy condition the enhanced sum insured of Rs.55,000/- shall be considered as a fresh policy and all the conditions and restrictions applicable to the fresh policy will be applicable to the enhanced amount. As per condition No.6 [c] of the renewal policy the complainant is entitled to get a maximum of Rs.51,750/-. Hence prays for the dismissal of the complainant. According to the complainant in the renewal policy the coverage was enhanced to Rs. 1 lakh from 45,000/-. The claim of Rs.150769/- was limited to Rs.51750/- without showing reason. As per the opp.party as per condition No. 6[c] in Ext.D1the enhanced sum insured will not be available for illness, disease, injury already contracted under the proceeding policy period. The learned counsel for the complainant argued that the said condition does not find a place in the condition attached to Ext.P1 policy. On verification it is seen that Ext. P1 is the Mediclaim Insurance Policy but Ext. D1 is the mediclaim policy of 2007. In Ext. D1as per condition 6 [c] the above said condition is specifically mentioned. As per Ext. D1 the enhanced sum insured of Rs.55,000/- is a new policy and the complainant is not entitled to get any claim for the illness already contract to him during the proceeding policy period. Ext. D3 the discharge summary from the SUT hospital and Ext. D5 and more over during cross examination PW.1 admits that he was suffering from the disease of coronary artery disease for the last 6 years. As per policy condition 4.1 of Ext. D1 the pre-existing diseases are excluded from the insurance coverage when the cover incepts for the first time. Hence as per condition 4.1 and 6[c] of Ext. D1 the complainant is not eligible to get any claim for the enhanced sum insured of Rs.55,000/- . By considering the previous sum insured of Rs.45,000/- the opp.party has already sanctioned Rs.51,750/-. In these circumstances we are of the view that there is no defici9ency in service on the part of the opp.party. Point found accordingly. In the result the complaint fails and the same is hereby dismissed. Dated this the 29th day of June, 2010. . I n d e x List of witnesses for the complainant: PW.1. – K.V. Gopalakrishna Pillai List of documents for the complainant P1. – Policy certificate P2. – Registered notice dt. 23.5.05 P3. – Postal A/c P4. – Postal Acknowledgement 24.5.08 P5. – Notice dated 24.6.2008 P6. – Postal A/c. dt. 26.6.08 P7. – Postal Ack. Dt. 25.6.08 P8. - Adv. notice P9. – Postal Ack. Dt. 31.7.05 P10. – Acknowledgement dt. 2.8.08 P11. – Postal cover dt. 11.9.08 List of witnesses for the opp.parties : NIL List of documents for the opp.parties D1. – Duplicate schedule D2. – Policy paperDischarge summary D4. – Mediclaim policy D5. Order copy of O.P.No.205/2005 | 
