O R D E R<br /> Smt. C. Lathika Bhai (Member) <br /> <br /> The complainant Salim Kumar, Ambady, Doctor’s Lane, Pathanamthitta has filed this complaint against the opposite parties for getting a relief from the Forum.<br /> <br /> 2. The complainant’s case is as follows:- The complainant had taken a medi-claim policy bearing No.570204/48/2002/8500112 from the opposite party. The said policy covered the period from 14.5.02 to 13.5.03. On October 2002, the complainant had developed acute pain in his right eye and he was admitted in Chaithanaya Eye Hospital & Research Institute, Thiruvananthapuram. He was treated from 18.10.02 to 23.10.02. there and thereafter on 23.10.02, the complainant was referred to Aravind Eye Hospital, Madurai. After returning from Madurai hospital, the complainant preferred a claim before the opposite party for reimbursement of his medical expenses. The opposite parties repudiated the claim without any valid reasons. The repudiation of the claim amounts to a deficiency of service and violation of terms and condition of the policy. The complainant filed this complaint for getting his medical expenses and reasonable compensation for his mental agony and other inconvenience caused due to the above said repudiation with cost from the opposite parties. The complainant prays for granting a relief.<br /> <br /> 3. For the opposite parties, the 2nd opposite party has filed a common version for him and on behalf of the 1st opposite party with the following contentions: The opposite parties are admitting the medi-claim policy and its validity from 14.5.02 to 13.5.03. It is further admitted that the complainant had lodged a claim form for getting of Rs.3.962/- being the expenses of treatment to his right eye. The claim was repudiated according to Clause IV(i) of the terms and conditions of the medi-claim insurance policy. As per Clause Iv(i) of the terms and conditions all deceases which existed prior to the commencement of the policy are excluded from the coverage under the policy. The policy commences from 14.5.02 for one year. The claim form put by the complainant had disclosed that he came to know about the illness on 18.4.02. It is clear that the disease is existed on 14.5.02, the date of commencement of the policy. The opposite parties repudiated the claim with reasonable ground and there is no deficiency in service from the opposite parties. The complainant does not deserve any benefit under the policy. Hence no mental agony caused to him and he is not entitled to get any compensation from them, and the complainant is liable to compensate the opposite party for dragging them to a vexatious litigation. The opposite parties canvassed for dismissal of the complaint. <br /> <br /> 4. The points for consideration in this complaint are the following:-<br /> <br /> (1) Whether the complaint is maintainable before this Forum?<br /> (2) Whether the complainant is entitled to get a relief as prayed for in the<br /> complaint?<br /> (3) Reliefs and Costs?<br /> <br /> 5. The evidence in this case consists of the oral evidence of the complainant who has been examined as PW1 and the documents produced by him was marked as Ext.A1 and A2 on the basis of the proof affidavit. For opposite parties, one witness was examined as DW1 and Ext.B1 and B2 were marked. After closure of the evidence, both sides heard.<br /> <br /> 6. Points 1 to 3:- The complainant is a consumer and the dispute herein is a consumer dispute and hence this complaint is maintainable before the Forum.<br /> <br /> 7. The complainant, PW1 deposed that he had taken a medi-claim policy valid from 14.5.02 to 13.5.03 from the opposite party. The policy certificate produced by the complainant is marked as Ext.A1. PW1 filed claim form before the opposite party for getting medical expenses incurred for the treatment of his right eye. But the claim was repudiated by the opposite party without assigning any valid reasons. The repudiation letter dated 12.2.03 produced by PW1 is marked as Ext.A2. PW1 filed this complaint for getting the medical expenses along with compensation and cost from the opposite parties. PW1 prays for allowing the complaint.<br /> <br /> 8. The learned counsel for opposite parties cross-examined PW1. At the time of cross-examination, he stated that he had not taken any medi-claim policy before this policy and he was aware that the claim is not allowable if there is any pre-existing disease to the insured at the time of taking the policy and his claim was repudiated on the ground that his disease was pre-existing at the time of taking policy. By answering a question put by the learned counsel for opposite parties, PW1 stated that the claim form was filled by the agent and it was signed without reading and the date of disease first detected was recorded by the agent himself and he came to know it only on receiving the repudiation letter. The claim form signed by PW1 produced by the opposite parties is marked as Ext.B1 through PW1. <br /> <br /> 9. For opposite parties, one witness, their agent was examined as DW1. At the time of examination of DW1, DW1 stated that the complainant was taken the medi-claim policy through his agency. Ext.B1 shown to DW1, he denied that the handwriting in Ext.B1 is not of him and stated that he is not aware of the claim form and it was not filled by him. The terms and conditions of the Ext.A1 policy produced by the opposite party is marked as Ext.B2 through DW1. He also stated that the claim form was not given by him.<br /> <br /> 10. The evidence from the part of the complainant, Ext.A1 is the copy of the medi-claim policy taken by the complainant. Ext.A2 is the repudiation letter sent by the opposite parties to the complainant.<br /> <br /> 11. Evidence from the part of the opposite parties, Ext.B1 is the claim form signed by the complainant and Ext.B2 is the terms and conditions of the Ext.A1 medi-claim policy.<br /> 12. The complainant’s case is that he had taken a medi-claim policy from the opposite parties and he had undergone treatment for the disease of his right eye and he filed a claim form before the opposite parties for getting the medical expenses as his treatment was during the policy period. But the complainant’s claim was rejected by the opposite parties as his disease was a pre-existing disease at the time of taking the policy. Complainant filed this complaint for realising the medclaim amount from the opposite parties and he prayed for allowing the complaint.<br /> <br /> 13. Opposite parties contention is that as per the terms and conditions of the medclaim policy, the diseases existed prior to the commencement of the policy are excluded from the coverage of the policy. In Ext.B1, the claim form, filed by the complainant before the opposite parties, the date when the disease first detected was written as 18.4.02. It is before the commencement of the policy on 14.5.02. Hence the claim was repudiated and the complainant is not entitled to get any amount as medical expenses and compensation or cost from the opposite parties.<br /> <br /> 14 With regard to this contention, the complainant argued that, the claim form was not prepared by him and it was prepared by the agent. The agent DW1 denied this and he stated that he was unaware of the claim form and it was not prepared by him. He also stated that the handwriting therein is not of him. But the complainant does not take any step for contradicting DW1’s statement or the opposite party’s contentions. On comparing the handwriting in the claim form and with the handwriting in the signature of the complainant, it is seen similar to the handwriting of the complainant. The signature in the claim form is also admitted by the complainant. In the circumstances, we have no reason to disbelieve the contentions put forward by the opposite parties. Therefore, this complaint is not allowable as the complainant’s ailment is a pre-existing disease and is liable to be dismissed. <br /> 15. In the result, this complaint is dismissed. No cost allowed.<br /> <br /> Declared in the Open Forum on this the 24th day of September, 2008.<br /> <br /> C. Lathika Bhai,<br /> (Member). <br /> Sri. Jacob Stephen (President) :<br /> <br /> Sri. N. Premkumar (Member) :<br /> <br /> <br /> <br /> Appendix:<br /> <br /> <br /> Witness examined on the side of the complainant:<br /> PW1 : P.K. Salim kumar<br /> Exhibits marked on the side of the complainant:<br /> A1 : Photocopy of the Policy Certificate issued by the 1st opposite party <br /> to the complainant.<br /> A2 : Repudiation letter dated 10.2.03 issued by the 1st opposite party<br /> to the complainant.<br /> Witness examined on the side of the opposite parties:<br /> DW1 : Roy George<br /> Exhibits marked on the side of the opposite parties:<br /> B1 : Claim form signed by the complainant produced by the opposite party.<br /> B2 : Terms and Conditions of the medi-claim policy.<br /> <br /> (By Order)<br /> <br /> Senior Superintendent<br />