By. Sri. K. Gheevarghese, President:-

The complaint filed against the opposite party for the repudiation of the insurance claim.

2. The complaint in brief is as follows:- The complainant and his family members had been included in Group Insurance Policy from 2007 onwards. The premium amount was remitted through the 2^nd opposite party. The terms and conditions of the policy provides that if the complainant or any member of the family availed treatments from hospital as an inpatient the medical expenses for the treatments is to be met by the 1^st opposite party.

3. The complainant's elder daughter had undergone treatment as inpatient from Vinayaka Hospital, Sulthan Bathery. Thereafter for expert management the patient was referred to Bathery Government Hospital and later to Medical College Hospital, Calicut. The patient died from Medical College Hospital due to high fever on 20.08.2010.

4. After the death of the complainant's daughter, to get the treatment expenditure a claim was forwarded to 1^st opposite party through the 2^nd opposite party. The claimant already spent more than Rs.30,000/- for the treatment of this child. However the claimable amount is as per the documents is Rs.14,898/-. The complainant was in possession of medical bills of Rs.14,898/- and the same was forwarded to 1^st opposite party for the granting of the claim. The 1^st opposite party repudiated the claim of the complainant on the ground that the disease is pre-existing. There may be an Order directing the opposite parties give the complainant the medical expenditure of the bills forwarded to the 1^st opposite party of Rs.14,898/- and interest at the rate of 12% from 20.09.2010 onwards.

5. The 1^st opposite party filed version in short it is as follows:- The complainant and his family members were included in Group Insurance Policy of the Sreyas members. The complainant filed claim before this opposite party on the medical expense of the complainant's daughter. The claim was repudiated by this opposite party on the ground that the illness was pre-existing. The policy conditions do not permit this opposite party to provide the claim for pre-existing disease. The complainant's daughter was bedridden for many years. The documents produced by the complainant also exemplify that the illness of the deceased was pre-existing. The complainant is not entitled to get any claim amount. Hence it is to be dismissed with cost.

6. The 2^nd opposite party is declared exparty.

7. The points that are to be decided:-

1. Is there any deficiency in service on the part of the opposite parties?

2. Relief and Cost.

8. Points No.1 and 2:- The evidence in this case consist of the proof affidavit of the complainant. Exts.A1 and Exts.B1 to B5 are the documents produced. The oral testimony of the complainant is also brought out in this case.

9. The complainant's case is that the elder daughter of the complainant availed medical treatment and the expenses claimable as per the scheme of the policy is repudiated by the 1^st opposite party on the ground that the deceased had pre-existing decease. It is admitted by the opposite party that the complainant and the family members belong to the Group Insurance Policy of the Sreyas family members. The complainant himself belong to member in Sreyas. The complainant was examined as PW1. The ailment of the deceased was Cerebral Palsy. Ext.B1 is the Medical Certificate issued by Dr. Jayesh, who treated the patient from Medical College Hospital, Calicut. This documents on observation reveals that the patient had prolonged fever. The ailment was diagnosed as Cerebral Palsy and this Doctor was consulted for the first time on 9^th July 2010. The patient died from Medical College Hospital, Calicut on 20.08.2010. Apart from the certificate issued by Dr. Jayesh ie marked as Ext.B1, no other documents are produced to establish the contention of the opposite party that whether the patient had the same ailment which caused death at the time of her inception to the policy. The complainant produced medical bills of Rs.14,898/-.

10. The repudiation of the claim amount by the 1^st opposite party is deficiency in service. The 2^nd opposite party is only a processing agent and they are delated from any liability.

In the result the complaint is partly allowed. The 1^st opposite party is directed to pay the complainant Rs.14,898/- (Rupees Fourteen Thousand Eight Hundred and Ninety Eight Only) the medical expenses met by the complainant as per documents along with interest at the rate of 12% from the date of filing of this complaint till payment of the amount. The complainant is also entitled to get Rs.500/- (Rupees Five Hundred Only) towards cost. This is to be complied by the 1^st opposite party within one month from the date of receipt of this Order.

Pronounced in Open Forum on this the day of 30^th April 2012.

Date of Filing:15.11.2011.