Sri. Jacob Stephen (President)<br /> <br /> The complainants Mr. M.V. Daniel, Saramma Daniel and Deena Daniel, Valukattil House, Chengaroor.P.O., Mallappally filed this complaint against the opposite parties 1 to 3, who are the Manager, New India Assurance Co., Changanassery, Divisional Manager, New India Assurance Co., Kollam and the Branch Manager, New India Assurance Co., Pathanamthitta, for getting a relief from the Forum.<br /> <br /> 2. The facts of this complaint reads as follows:- The petitioners are holders of hospitalization and domiciliary Hospitalization Benefit Policy No.760102/48/01/13021 of the opposite parties issued from the office of the 1st opposite party and it is valid from 14.2.2002 to 13.2.2003. While so, the 1st complainant had to undergone treatment as inpatient at Thiruvalla Medical Mission Hospital for 9 days from 22.9.2002 to 1.10.2002 and had spent Rs.11,610/- (Rupees Eleven thousand six hundred and ten only) towards treatment. Thereafter, the petitioner put up claim along with all relevant documents, before the 1st opposite party for getting the treatment expenses as they have got a valid policy for the same. But the respondents have not allowed the claim in spite of the complainants repeated request. Later, the 1st complainant requested the 1st opposite party to return the original documents submitted by him. 1st opposite party asked that if they withdraw the claim, the documents will be returned. Ultimately, the complainants were forced to tender such an endorsement over the request letter and received back the documents. That does not mean that they have given up their legal right to get a claim under a valid policy. Rejection of the claim by the opposite parties is illegal and they are liable to pay the treatment expenses. Therefore, this O.P is filed for getting an order from this Forum for the release of Rs.11,610/-, the treatment expenses of the 1st opposite party along with compensation of Rs.10,000/-, for the mental agony and physical strain caused to the complainant and the cost of this proceedings.<br /> <br /> 3. For the opposite parties 1 to 3, the 3rd opposite party filed a common version raising the following contentions. Opposite parties are admitting the policy and the validity of the policy of the complainants. They are also admitting claim petition for the reimbursement of the treatment expenses. Along with the claim form, the complainant had submitted the discharge summary issued from Thiruvalla Medical Mission Hospital and it is seen that the complainant had undergone treatment at Carithas Hospital, Kottayam and the treatment records of Carithas Hospital produced by the complainant shows that the complainant has undergone treatment at Carithas Hospital from September 1999 onwards for Unstable Angina a severe heart problem. So the complainant had taken the policy by suppressing the pre-existing disease, which is not covered under the policy and excluded in Clause 4.1 of the Medi claim policy, and hence they have repudiated the claim on 22.1.2003. Thereafter on 19.5.2003, the 1st complainant submitted a request for the return of the original documents submitted by him stating that he intents to submit a claim before Ration dealers Welfare Fund as his wife is a ration dealer licensee and the documents are demanding not for filing any case against the opposite parties and he made this statement as he is fully aware that he is not entitled to get claim from the opposite parties and he had withdrawn the claim unconditionally by endorsing it on the request letter. Apart from this, the complainant had send a lawyer’s notice for settling the claim for which the 1st opposite party send a reply also through opposite parties advocate in which all the facts and circumstance, which led to the repudiation of the claim was also stated. In the circumstances, this O.P is not maintainable and the complainant is estopped from taking such a contention. Therefore, they prayed for the dismissal of this O.P with their cost.<br /> <br /> 4. The points for consideration in this O.P are the following:-<br /> (1)Whether this complaint is maintainable either in law or<br /> on facts?<br /> <br /> (2)Whether the complainant is entitled to get a relief as prayed<br /> for in the complaint?<br /> <br /> (3)Relief and Costs?<br /> <br /> 5. The evidence in this O.P consists of the oral evidence of the 2nd complainant who has been examined as PW1. Exts.A1 to A4 were marked in support of the case of the complainant as per the proof affidavit filed by the 2nd complainant and the oral evidence of the 1st complainant who has been examined as PW2. The opposite parties have no oral evidence. But 3 documents were marked for opposite parties as Exts.B1 to B3 in support of the case of the opposite parties. Ext.B1 and B2 were marked through PW1 and B3 is marked as per the order of the Forum on 4.4.07. After closure of evidence of both sides were heard.<br /> <br /> 6. Point No.1:- This complaint is maintainable as the complainant is a consumer of the opposite parties and the dispute is a consumer dispute.<br /> <br /> 7. Points No.2 to 3:- The complainants allegation is that opposite parties has not given the medical expenses incurred by him though he had a valid policy for medi claim. Opposite parties contention is that the medical expenses incurred by the complainant is for a pre-existing disease and it is not covered by the policy as per Clause 4.1 of Ext.B3.<br /> <br /> 8. It is interesting to note that the complainant have not stated either in the complaint or in the proof affidavit that for what disease he had undergone treatment. He disclosed the nature of his disease, for which he had undergone treatment, only at the time of cross-examination. In order to prove the complainants case, he had produced a photocopy of the details of I.P.Bill No.209248 dated 26.10.2002 prepared in the letter pad of Thiruvalla Medical Mission, which was marked in Ext.A4 subject to the objection of the opposite parties. Ext.A4 is not a medical certificate. It contains only the list of medicines and such other things, which cannot be considered as a conclusive evidence for the complainant’s case. The complainant had no other evidence to prove his case. But he had stated in his deposition that all the originals of the medical treatment records are submitted before the Taluk Supply Officer, Mallappally for getting certain benefits from the Ration Dealers Welfare Fund. But nothing is brought out in evidence regarding the result of the claim application submitted before Taluk Supply Officer, Mallappally. So it is doubtful, under what circumstances, the medical records are not produced before the Forum.<br /> <br /> 9. On the other hand, the opposite parties specific case is that, the claim of the complainant is in respect of pre-existing disease. In order to prove that aspect, the opposite parties produced a photocopy of the complainant’s discharge summary issued by Thiruvalla Medical Mission Hospital, which is marked as Ext.B1 through PW1 and as per B1(a) entry, the complainant was undergone treatment at Carithas Hospital, Kottayam. The complainant’s explanation is that he had not undergone any treatment at Carithas, but he had gone for check up and it is also at Cardiology Department. If the complainants’ explanation is true, what prevented him to produce the treatment records of Carithas Hospital before the Forum.<br /> <br /> 10. Considering the nature of the disputes between the parties, medical records are highly necessary for the final decision of this case. It is the duty of the complainant to prove his case by convincing the Forum by adducing oral and documentary evidence. Here there is no documentary evidence either to prove the complainants case or to disprove the opposite parties defence. The evidence brought by the complainant is not sufficient to prove his case and thereby the complainant failed to establish his case. Hence we find no merit in this case. <br /> 11. In the result, this O.P. is not allowable and hence dismissed. No cost.<br /> Declared in the Open Forum on this the 25th day of April, 2008. <br /> <br /> (Sd/-)<br /> Jacob Stephen,<br /> (President). <br /> <br /> Smt. C. Lathika Bhai (Member) : (Sd/-)<br /> <br /> Sri. N. Premkumar (Member) : (Sd/-)<br /> <br /> Appendix:<br /> Witness examined on the side of the complainants:<br /> PW1 : Saramma Daniel.<br /> PW2 : M.V. Daniel.<br /> Exhibits marked on the side of the complainants:<br /> A1 : Hospitalisation and Domiciliary Hospitalisation Benefit Policy<br /> Certficate from 14.2.2002 to 13.2.2003.<br /> A2 : Mediclaim Insurance Policy Certificate from 14.2.2001 to 13.2.2002.<br /> A3 : Mediclaim Insurance Policy Certificate from 14.2.2000 to 13.2.2001.<br /> A4 : Copy of the Medical Bill dated 26.10.2003 obtained from the<br /> Thiruvalla Medical Mission Hospital.<br /> Witness examined on the side of the opposite parties : Nil.<br /> Exhibits marked on the side of the opposite parties:<br /> B1 : Photocopy of Discharge Summary.<br /> B2 : Letter sent by the first complainant to the first opposite party.<br /> B3 : Mediclaim Insurance Policy.<br /> <br /> <br /> <br /> <br /> (By order)<br /> <br /> <br /> <br /> <br /> <br />