By Smt. Padmini Sudheesh, President: <br /> <br /> Petitioner’s case is as follows:<br /> <br /> 1. Petitioner is holder of Pravasi Suraksha Kudumba Arogya Scheme Policy Certificate No.1999/47/760500/80729 (760301) issued on 18.6.99 valid upto 17.6.04. He has taken the policy while he was a non-resident Indian. On 7.10.2001 the Lions Club of Kodungallur had organised a Free Eye Camp at Kodungallur. During this period the petitioner had some eye irritation and dimness of vision and he had attended the free eye camp for eye check up. The doctors advised for a Cataract operation. They organized for free cataract operation at Aravind Eye Hospital, Coimbatore. He was admitted on 29.10.2001 and discharged on 4.11.2001 after the cataract operation. All these incidents have taken place 28 months after joining in the policy. After returning from the Aravind Eye Hospital, the petitioner filed his claim with the respondents on 19.11.2001 for Rs.8947.10 and the respondents accepted the claim and passed Rs.6613/- as insurance compensation excluding the travel expenses. Since the petitioner did not get expected relief, he again consulted a doctor and he was referred to Sreedhareeyam Ayurveda Gaveshana Kendram, Koothattukulam for continued treatment of his eye. He was admitted in the Kendram on 11.9.02 and discharged on 3.10.02. After return from the Kendram the petitioner filed his insurance claim before the respondents claiming an amount of Rs.11,871/-. The petitioner had to be undergone treatment in Chaithanya Eye Hospital and Research Centre, Kesavadasapuram, Thiruvananthapuram for eye operation as a continued treatment to recover his eye sight. He was admitted in the Chaithanya Eye Hospital, Thiruvananthapuram on 5.12.2002 and discharged on 7.12.02 after the eye operation. The petitioner had to spent Rs.18,850.55 towards operation, travel expense and hospital expenses. After return from the hospital the petitioner claimed Rs.18,850.55 as policy benefits from the respondents. After claiming the benefits on 9.4.03, the first respondent informed the petitioner that they have conducted an investigation and alleged that the petitioner was having cataract since 4 years and they are unable to entertain both the claims as all pre-existing diseases are excluded from the scope of the policy. They denied the insurance claim and this complaint has filed. <br /> <br /> 2. The version filed by the respondents is as follows: The respondents admitted that the petitioner is a policyholder and the policy is valid from 18,6.99 to 17.6.04 subject to the terms and conditions. The disease for which he was admitted in various hospitals are not for the continuous treatment of the pre-existing disease. The Company had conducted an investigation and it is revealed that he was suffering from cataract for four years. According to the Pravasi Suraksha Kudumba Arogya Scheme all pre-existing disease are excluded. Since the claim is not come under the purview of the policy, the first respondent repudiated the claim by letter-dated 9.4.03. The petitioner has not disclosed these disease earlier. Hence the petition is to be dismissed. <br /> <br /> 3. The points that arise for consideration are:- <br /> <br /> (1) Whether the petitioner is entitled for the insurance claim?<br /> (2) Whether the petitioner is entitled to get compensation as prayed?<br /> (3) Reliefs and costs. <br /> <br /> 4. The evidence consists of Exts. P1 to P13. No document is produced from the part of the respondents.<br /> <br /> 5. Point No.1 & 2: The petitioner’s case is that as per the policy he is entitled for the treatment expenses. But the claim has repudiated by the respondents stating that on the basis of the investigation done by them the petitioner was suffering from the disease since 4 years. According to the respondents, as per the PSKA Scheme all pre-existing diseases are excluded from the scope of policy benefits. But this version cannot be accepted at all. Ext. P1 reveals that before taking of the policy, medical check-up is not necessary and an affidavit is enough and it need not be solemnized by the policyholder himself. So the contention of exclusion of pre-existing disease from the purview of the policy benefit is not at all admissible.<br /> <br /> 6. More over, the respondents had accepted the first medi-claim of the petitioner in October 2001 for cataract and it was after two years of joining in the policy. Later repudiating the further claims alleging pre-existing disease is illegal and it is rejection of a genuine medical claim. The insurance is being taken for financial assistance and if it is rejected by the Insurance Company on unreasonable grounds the very purpose will be futile. So the petitioner is entitled for the insurance benefits and the point is found against the respondents. <br /> <br /> 7. Point No.3: Exts. P5 and P6 are the documents revealing the expenses. As per Ext. P5 he claims Rs.18,850-55, but for the columns 6 to 20, not including column 20, there is no bill and only can be assumed. For these columns he claims Rs.3132/-, but we find that he is entitled to get only Rs.2000/- towards the travelling expenses. Likewise, column 4 of Ext. P6. The petitioner claims Rs.2000/- towards the travelling expenses. There is no evidence for the same. We find that he is entitled for Rs.1000/-. So as per Ext. P5, the petitioner is entitled to recover from the respondents Rs.17,718/- only and as per Ext. P6, the petitioner is entitled to get Rs.10,871/- only.<br /> <br /> 8. In the result, the petition is allowed and the respondent is directed to pay Rs.28,589/- (Rupees twenty eight thousand five hundred and eighty nine only) to the petitioner with interest at the rate of 12% per annum from 7.10.2002 and 6% interest from today till realization. Time for compliance one month. <br /> <br /> Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 12th day of May 2008.<br /> <br />