By Smt. Padmini Sudheesh, President: The case of complainant is that the complainant was a policy holder of respondent vide No.760302/48/02/00151. The name of the policy is Mediclaim Insurance Policy or Hospitalization and Domiciliary Hospilisation Benefit Policy. The policy had coverage from 26.4.02 to 25.4.02. The complainant paid Rs.2329/- as the premium amount and the assured amount is Rs.2,00,000/-. As per the policy the respondent is liable to reimburse the medical expenses incurred in accident also. On 21.6.02 at 2.30 p.m. while the complainant was travelling as a pillion rider in a motor cycle No.KL7/7450 had met with an accident and sustained injury. He was treated in Government Hospital, Kunnamkulam as an outpatient by O.P.No.24662. He was discharged and taken rest in his house. The injuries were not healed and he had undergone ayurvedic treatment also. In spite of this he was not recovered fully and on 26.7.02 he was admitted in Heart Hospital, Thrissur and discharged on 13.8.02. It was found out that there occurred fracture to hip and surgery was conducted. After that he was again admitted in the Heart Hospital on 21.11.02 and surgery to hip was again conducted. By these two surgeries the hips of left and right were replaced. Being the insurance policy holder the complainant is eligible for reimbursement of medical expenses. So he submitted claim to the respondent with all relevant documents. The Vadakkekkad Police registered the accident as crime No.35/03. The claim of complainant was not honoured by the respondent by stating delay in submitting the claim and the complainant filed OP.427/03 before this Forum and it was ordered to explain the delay caused to submit the claim. It was done and the respondent intimated to the complainant that since the complainant was suffering from pre-existing disease he is not eligible for claim benefit. There occurred Rs.2,00,000/- as the expenses for treatment. The complainant is entitled to get this amount and this complaint is filed. 2. The respondent filed counter by stating that the averments in the complaint that on 21.6.02at 2.30 while the petitioner was travelling as pillion rider in vehicle No.KL-7/7450 motor cycle, sustained injuries, he was admitted in Govt. Hospital, Kunnamkulam as OP No.24662 and discharged, thereafter the complainant took rest in the home etc. are not correct and denied by this respondent. The document marked as Ext. R5 in OP.427/03 and the investigation conducted would reveal that the complainant was treated at Kozhikode Devi Hospital during 1998 and also in Kottakkal Arya Vaidyasala during 1999 for his back pain. He was admitted in Devi Hospital for 7 days and at Kottakkal for 15 days. According to the direction of the Forum in OP.427/03 this respondent has condoned delay in submission of the documents and claim is considered afresh on merits. The investigation conducted by this respondent thereafter reveals that the person attended by the hospital as OP.No.24662 is one Mr. Sibi aged 24 years and not the complainant as alleged in the complaint. Therefore it is clear that the OP ticket and OP number on the basis of which the complainant has claimed the occurrence of RTA was not genuine or acceptable. The motor cycle KL7-7415 in which the applicant had allegedly been a pillion rider involved in the alleged accident was driven by his brother-in-law and immediately after the alleged accident neither the petitioner nor the hospital authorities of Kunnamkulam Govt. Hospital reported the matter to the police under the Medico Legal Provisions. Further the doctor of the hospital confirmed that there had been no external injury or visible difficulties to the applicant after the alleged accident. The police registered the FIR on a private complaint. If the complainant had sustained any injury warranting hip replacement definitely the hospital authorities would have recorded the same and police would have been informed also. After the alleged OP treatment the applicant had not consulted in any hospital for a period for about two months. The complainant had been treated as IP 20961 in Thrissur Heart Hospital for kidney problems. The applicant has availed mediclaim policy for Rs.2,00,000/- on 26.4.02 which is approximately the amount required for surgery in connection with replacement of his right and left hip. The applicant was admitted to the Heart Hospital, Thrissur after three months, on 26.7.02 with the history of fall before one month. The applicant had been diagnosed by the doctors for a vascular neurosis and it is symptomatic of very earlier accident/injury and medically the injury can’t be within two months. This is an indicative and confirmed fact to prove that the petitioner had been suffering from the ailment before the inception of the policy on 26.4.02. Even though this respondent admits the policy for the period from 26.4.02 to 24.5.03 in the name of Mr.M.V. Suresh Babu as per clause 4.2 reimbursement of expenses for treatment of any pre-existing condition or ailment is an exclusion. According to the order of the Forum in OP.427/03 this respondent had condoned the delay in submission of documents and the petitioner’s claim was considered afresh on merits. Thereafter the claim has been rejected on the above stated grounds. There is no deficiency in service from the side of this respondent. Hence dismiss the complaint. 3. The points for consideration are: (1) Whether there was any deficiency in service on the part of respondent? (2) If so, reliefs and costs. 4. The evidence consists of Exts. P1 to P14 and the deposition of PW1 on the part of complainant and Exts. R1 to R15 and deposition of RW1 on the part of respondent. 5. Points: It is the case of complainant that he is a subscriber of Hospitalisation and Domiciliary Hospitalisation Benefit Policy of respondent vide policy No.760302/48/02/00151. The coverage of the policy was from 26.4.02 to 25.4.03. The insured amount was Rs.2,00,000/- and he paid Rs.2329/- as the premium amount at the time of joining the policy. 6. According to the complainant on 21.6.02 at about 2-30 p.m. while he was travelling as pillion rider in a motor cycle bearing No.KL-7/7450 a motor accident was occurred and he had sustained injuries. According to him, he was immediately taken to Govt. Hospital, Kunnamkulam and was treated as out patient by OP No.24662. But his decease was not cured and he had undergone for Ayurvedic treatment also. There was no result from Ayurvedic treatment and he was admitted on 26.7.02 in Heart Hospital, Thrissur. He was treated there as inpatient till 13.8.02. It was found that he had fracture to the hip and surgery was conducted. Again on 21.11.02 he was admitted in the same hospital and another surgery to hip was conducted. The surgeries were to replace the left and right hips. After the treatment he had applied for the insurance benefits with the Company, but it was repudiated by them by stating delay in claim. So the complainant approached this Forum by OP.No.427/03. In OP.427/03 the Forum directed the petitioner to explain the delay by notice in writing within one month and to dispose the claim by the respondent. So the complainant again applied by explaining the delay and the respondent again rejected the claim by stating pre-existence of disease. So the point to be considered in this case is whether the complainant was suffering from the same disease before the subscription of the policy. 7. The case of complainant is that a motor accident occurred on 21.6.02 and injuries were sustained to him. Immediately he was taken to the Govt. Hospital Kunnamkulam and treated as out patient. The OP number stated by the complainant is 24662. He has produced the OP ticket and it is marked as Ext. P4. The respondent challenged the genuineness of this OP ticket. According to them, the investigation conducted by them reveals that the person attended by the hospital as OP No.24662 is one Mr. Sibi aged 24 years and not the complainant as alleged in the complaint. So according to them the OP ticket and OP number on the basis of which the applicant has claimed the occurrence of RTA is not genuine or acceptable. 8. There were two investigators and Investigator Anthony is examined as RW1 and his report is marked as Ext. R8. He deposed that he has conducted an enquiry at Kunnamkulam Govt. Hospital and it was found that one Sibi was treated as OP No.24662. As per Ext. R1 the respondent enquired about the genuineness of Ext. P4. The Superintendent of Government Hospital, Kunnamkulam sent a reply to respondent and the reply is produced along with the postal cover and is marked as Exts. R12 and R13. Ext. R12 is the reply sent by the hospital. It is stated in Ext. R12 that on verification of O.P. register an admission namely Suresh aged 32 vide O.P.No.24738 on 21.6.02 seen in the register. OP No.24662 dated 21.6.02 the name of patient is Sibi aged 24 years as per OP register. So according to the respondent the complainant made Ext. P4 artificially to show that he had treated as out patient in Govt. Hospital, Kunnamkulam on 21.6.02. This version of the respondent cannot be believed at all. Ext. P4 is issued from Government Hospital Kunnamkulam and the medicines prescribed are seen. There is nothing unnatural in Ext. P4 to disbelieve the document. The concerned OP register is not produced for perusal of the Forum and we cannot believe only on the transactions between the hospital and respondent Company. If there was any forgery on the part of complainant it was the duty of hospital to initiate action against him. No such action was seen to be taken till date. It is specifically stated in the complaint that there was no external injury. The complainant who is examined as PW1 deposed that there was abrasion to his hands. According to him, first aid treatment was taken in the Govt. Hospital. 9. According to the complainant after consultation in government hospital his disease was not healed and he had taken ayurvedic treatment but it was also failed. So he had consulted doctors in Heart Hospital, Thrissur and it was diagnosed as Vascular Necrosis Right Hip. The discharge summaries from Heart Hospital are produced and marked as Ext. P6 and P7. Ext. P6 is the discharge summary showing the treatment to left hip. It can be seen that total hip replacement was done. The history of illness stated as fall one month back from bike in an RTA. As per Ext. P7 Bipolar hip replacement right was under G.A. on 27.11.02. The history and physical findings stated as complaints of pain right hip due to RTA. 10. It is the contention of respondent that immediately after taking the policy surgeries were conducted and he had availed mediclaim policy for Rs.2,00,000/- on 26.4.02 which is approximately the amount required for surgery in connection with replacement of his right and left hips. According to the respondent, the complainant after anticipating the expenses to hip surgery this policy was taken. According to the respondent, the complainant anticipated the problems and joined the policy. 11. According to them, the complainant had been diagnosed by the doctor a Vascular Necrosis and it is symptomatic of very earlier accident/injury and medically the injury can’t be within two months. According to them, this is an indicative and confirmed fact to prove that the complainant had been suffering from the ailment before the inception of the policy on 26.4.02. As per Ext. P6 and P7 the history of disease is fall from bike. There is no evidence of any other motor accident caused to the complainant. The version of RW1 is also that it is not proved that the injury to complainant is from some other accident. The respondent simply stated that the complainant was suffering from the disease before the inception of the policy. There is no evidence at all to prove that the complainant had been suffering from the ailment before the policy and there is no evidence at all for any treatment undergone by the complainant for the same disease. 12. Ext. R9 is a reinvestigation report in respect of mediclaim of complainant and it is stated by him that he was treated at Kozhikode Devi Hospital during 1998 and also treated in Kottakkal Aryavaidyasala in 1999 for his back pain. But there is no record to show that he had undergone treatments in such places. The disease is also different because as per Ext. R9 he had undergone treatment for his back pain. There is no evidence in support of Ext. R9 and he has not deposed before the Forum also. The repudiation of the present claim by the respondent Company is on the basis of pre-existence of disease. But they failed to prove that the complainant had the ailment before the inception of the policy. It was a deficiency in service on the part of respondent and the complainant is entitled for the claim amount. 13. The respondent disputed about the occurrence of accident by stating that the police had not been registered crime. It is true that crime was registered on private complaint. The police registered FIR by No.35/03 under Sections 279 and 338 of I.P.C. As per the FIR when the motor cycle was immediately turned from the direct route by seeing a gutter the complainant who was the pillion rider fell on the road. From the records it can be seen that there was motor accident as stated by complainant and the complainant had sustained injuries. As per Ext. P2 disability certificate from Medical College Hospital, Thrissur the complainant is having disability of 50%. The respondent failed to prove the pre-existence of the disease and the complainant is entitled to get the treatment expenses from the respondent with compensation. 14. In the result the complaint is allowed and the respondent is directed to pay the Ext. P5 series bills amount with interest at the rate of 12% per annum from the date of first complaint ie. 19.6.03 till realization with costs Rs.1000/- (Rupees one thousand only) to the complainant within one month from the date of receipt of copy of this order. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 28th day of July 2010.
| | [HONORABLE Rajani P.S.] Member[HONORABLE Padmini Sudheesh] PRESIDENT[HONORABLE Sasidharan M.S] Member | | 
