D.o.F: 21/1/09 D.o.O:18/11/09IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD CC.16/09 Dated this, the 18th day of November 2009. PRESENT: SRI.K.T.SIDHIQ : PRESIDENT SMT.P.RAMADEVI : MEMBER SMT.P.P.SYAMALADEVI : MEMBER K.Madhavan, S/o Bairan, R/at Ram Nivas, Near Post office, : Complainant Anandashram PO,Kasaragod. (Adv.T.M.Jose,Kanhnagad) 1. The Manager, United India Insurance Co.Ltd, Vettukattil Buildings,M.G.Road, Kochi,Ernakulam. 2. The Authorised Officer, : Opposite parties Family Health Plan Ltd, No.39/4967 G, Uznaz Towers, 5th floor, Medical Trust Junction,Pallikunnu, M.G.Road,Ernakulam. (Adv.C.Damodaran,Kasaragod) ORDER SRI.K.T.SIDHIQ: PRESIDENT The complaint is filed against the repudiation of medi claim by the opposite party relying on the exclusion clause 8.2 of the policy that the disease is contracted within 30 days of waiting period from the date of commencement of policy and the disease was a pre-existing one. 2. According to opposite party, the repudiation of the claim was as per policy terms and conditions since the claim of the complainant falls under 30 days waiting period and the disease was pre-existing the claim was a pre-existing one. 3. Complainant filed affidavit in support of his claim. Exts.A1 to A12 marked. On the side of opposite party Exts.B1 to B3 marked. Both sides heard and documents perused. 4. According to complainant, the opposite party had issued a mediclaim insurance policy under the Synd Arogya Group Mediclaim in which the complainant, his wife Shobhana, together covered with effect from 11/2/2006 to 10/2/2007 bearing policy No.100100/48/05/14/00000878 for a sum of Rs.50,000/-. Thereafter it was renewed. Though the premium was paid before the expiry of the policy the period of renewed policy was from 20/3/07 to 19/3/2008 with policy No.100100/48/06/14/00001084. So the policy is a continuing one of the preceding 12 months without any break. While so Smt.Shobhana , the wife of the complainant suffered giddiness and vertigo and pain on her ears. Since the pain on the ears in morning was unbearable, she consulted the doctors at Chennai Krishna Hospital on 19/4/2007. They suggested a surgery. But for the convenience the complainant took his wife to KMC Hospital Attavar,Mangalore and admitted thereon 26/4/07. The doctors of KMC Hospital after thorough investigation opined that surgery is not required and medicinal treatment is sufficient. Thereafter a claim was preferred with opposite party with bills for Rs.7722/- and other related documents. But the claim was repudiated. 5. According to opposite party, the policy issued for the period 29/3/2007 to 19/3/2008 was not a renewed policy but was a fresh policy and no premium was accepted prior to the expiry of the earlier policy. Hence the policy under which the claim made is not a renewed policy. Hence the disease contracted to the wife of the complainant was comes under the purview of clause 8-2 of the policy which says that ‘the disease contracted to the insured during the first 30 days from the date of commencement of policy is excluded.’ 6. The learned counsel for the complainant Sri.Rajeevan invited our attention to the policy in dispute and the policy covering the period 11/2/06 to 10/2/07. In both the policies the date of proposal is shown as 11/2/06. Relying on this date the learned counsel submitted that the policy is to be treated as a fresh one,otherwise there should have been a different proposal for the subsequent policy. His further contention is that the wife of the complainant Shobhana is hospitalized on 19/4/07 ie, with a complaint of nausea since morning on that day, the 31st day of renewal of policy even if the date of commencement is reckoned as 20/3/07. As against the contention of the opposite party that the disease contracted to the wife of the complainant is a pre-existing one the learned counsel for the complainant submitted that there is absolutely no evidence and it is only an allegation raised by the opposite party to escape from the liability to honour the claim. 7. We find some substance in the arguments advanced by Sri Rajeevan. The date of proposal of the policy is 11/2/06 in both the policies. So evidently there is no proposal for the policy covering the period 20/3/07 to 19/3/08. Without a proposal how the opposite party issued a fresh policy is quite unknown. So this point turns against the contention of opposite party that the policy for the period from 20/3/07 to 19/3/08 was a new one. Further no expert evidence is adduced by the opposite party to prove that the disease contracted to the wife of the complainant was a pre-existing one. In the absence of such evidence no reliance can be placed on this contention. Apart from that, it is seen that the wife of the complainant was seen consulted at Chennai Krishna Hospital with a complaint of nausea since morning on 19/4/07 ie, the 31st day of commencement of policy. So the exclusion clause 8.2 also will not help opposite party to save them from the liability of payment of claim. In the result, the complaint is allowed and opposite party is directed to pay Rs.7722/- to the complainant with a cost of Rs.2000/-. Time for compliance is 30 days from the date of receipt of copy of order. Failing which the amount of Rs.7722/- will carry interest @9% per annum from the date of complainant till payment. Sd/ Sd/ Sd/ MEMBER MEMBER PRESIDENT Exts: A1-Policy schedule A2-Photocopyof policy schedule A3-19/4/07-Photocopy of prescription issued by Chennai Krishna hospital A4—do- A5-Dischagrge summary A6-28/4/07- copy of cash bill of KMC Hospital A7-14/5/07- Copy of letter issued by complainant to OP.2 A8-4/10/07- ‘’ ‘’ OP.1 to complainant A9-1/12/07- “ “ OP.2 to complainant A10-30/8/08- Lawyer notice A11-&A12-Postal acknowledgment B1-& B2- Medical policies B3- Receipt of non premium collection Sd/ Sd/ Sd/ MEMBER MEMBER PRESIDENT eva/ /Forwarded by Order/ SENIOR SUPERINTENDENT
......................K.T.Sidhiq
......................P.P.Shymaladevi
......................P.Ramadevi | | 
