The case of complainant is as follows: The complainant was a policyholder of respondent vide policy No.2001/4876030115 503. The validity period of the policy was from 7.11.01 to 6.11.02. The present policy was the continuation of the earlier policy. The complainant was undergone treatment from 17.7.02 to 30.7.02. He vomited blood and admitted in Jubilee Mission Hospital, Thrissur. Surgery was also conducted. He had incurred medical expenses of Rs.33,046-21. Subsequently he had applied for policy benefit with all documents. On 28.11.02 respondent sent a letter intimating their inability to consider the claim. This is deficiency in service on the part of the respondent. Hence this complaint.

 

            2. The counter is as follows: The respondent has issued a policy under the policy No.760301/48/01/15503 for a period from 7.11.01 to 6.11.02 under the Medi Claim Insurance Policy in favour of complainant subject to the terms and conditions of the policy. The complainant has to prove that he has spent Rs.33,046/- by way of medical expenses. This respondent admitted that they have repudiated the claim on the ground that the treatment availed is for a pre-existing disease and this was intimated to the complainant vide letter dated 28.11.02. The petitioner has submitted a claim on 19.8.02 along with medical records. It was found some discrepancies in the records and for clarification of doubt the Company has obtained a medical certificate from attending doctor and shows that the insured was having cirrhosis of liver with portal hypertension diabetes. This documents also show that he was admitted in Jubilee Mission Hospital, Thrissur on 17.7.02 and under the treatment of gastro-enterologist Dr. T.K. Joseph for heavy gastro intestinal bleeding producing severe vomiting of blood. He was diagnosed as a case of Cirrhosis of liver with portal hypertension and fundic Oesophageai Varices bleed. An attempt of Seelero therapy was done which failed and was referred to Surgeon Dr. Vikraman and he underwent laparotomy and ligation of varices. Subsequently he was referred to P.V.S. Hospital, Cochin where he again underwent seelero therapy. Cirrhosis of liver with portal hypertension and oesophageal varices is a very chronic condition of years standing. Symptoms of bleed have come as a sudden complication. Patient is also a chronic diabetic shows that the treatment availed by the complainant is for pre-existing disease. The allegation that the medical record does not in any way substantiate the ground of repudiation of claim is not correct. The repudiation is based on the exclusion of the policy. The complainant has purposely suppressed the material facts from the Company. The claim preferred by the complainant is for a disease which was pre-existing and being fully aware that he has the ailment prior to issue of the policy. The repudiation is based on policy conditions and the complainant is not entitled for any reliefs. Hence dismiss the complaint.

 

            3. The points for consideration are:

(1)   Is there any deficiency in service?

(2)   If so, reliefs and costs.

 

            4. The evidence consists of Exts. R1 to R7, Ext. X-1 and the testimony of RW1. No evidence adduced by the complainant.

 

            5. Points-1 & 2: The case of complainant is that he being a policyholder of respondent vide policy No.760301/48/01/15503 entitled for the reimbursement of medical expenses incurred to him during the policy period. According to the complainant, he was treated in the Jubilee Mission Hospital Thrissur from 17.7.02 to 30.7.02 and incurred medical expenses of Rs.33,046/-. After that he had applied for the reimbursement of medical expenses. But was refused by the company. So he filed this complaint for appropriate relief. 

 

            6. In the counter the respondent stated that they issued a policy under the policy No.760301/48/01/15503 for a period from 7.11.01 to 6.11.02. The stated that they have repudiated the claim on the ground that the treatment availed by the complainant is for a pre-existing disease and this was intimated to him.   The petitioner has submitted a claim on 19.8.02 along with medical records. On going through the records the respondent found some discrepancies in the records and for clarification of doubts the Company has obtained a medical certificate from attending doctors, in which the petitioner was treated, shows that the insured person was having a cirrhosis of liver with portal hypertension diabetes. This documents also show that he was admitted in Jubilee Mission Hospital, Thrissur on 17.7.02 under gastro-enterologist Dr. T.K. Joseph for heavy gastro intestinal bleeding producing severe vomiting of blood, and was diagnosed as a case of Cirrhosis of liver with portal hypertension and fundic Oesophageai Varices bleed. An attempt of Seelero therapy was done which failed and was referred to Surgeon Dr. Vikraman and he underwent laparotomy and ligation of varices. Subsequently he was referred to P.V.S. Hospital, Cochin where he again underwent seelero therapy. Cirrhosis of liver with portal hypertension and oesophageal varices is a very chronic condition of years standing. Symptoms of bleed have come as a sudden complication. Patient is also a chronic diabetic shows that the treatment availed by the complainant is for pre-existing disease. The allegation that the medical record does not in any way substantiate the grant of repudiation of claim is not correct. The repudiation is based on the exclusion of the policy. The complainant has purposely suppressed the material facts from the Company. The claim preferred by the complainant is for a disease which was pre-existing and being fully aware that he has the ailment prior to issue of the policy. The repudiation is based on policy conditions and the complainant is not entitled for any reliefs. 

 

            7. Ext. R1 is the copy of repudiation letter produced by the respondent shows the intimation of the company to the complainant regarding the non-consideration of the claim. In the letter it is stated that from the medical records they have noted the complainant had Cirrhosis of liver with portal hypertension – diabetes. They also stated in the Ext. R1 letter that they advised by Medical panel that Cirrhosis of liver with portal hypertension and oesophageal varices is a very chronic condition of years standing. They have produced Ext. R3 medical certificate stating that the complainant has a disease of Cirrhosis of liver with portal hypertension and oesophageal varices is a very chronic condition of years standing.  In the certificate the Doctor opined that he feels this is a pre-existing disease. He also certified that at the effective date of the policy of 7.11.2000 and 7.11.2001 the disease was present. The certificate was issued by Dr. P.V. Francis, Professor of Surgery retired from Medical College Hospital, Thrissur. In the certificate he has stated that he referred the documents submitted to him. There is no mention about the details of documents referred by him. What all documents referred by him and the relevant dates of documents are not mentioned in the Ext. R3 certificate issued by the Doctor. The certificate contains his opinion only.

 

            8. Ext. R5 is the claim form submitted by the claimant shows the date of injury sustained as 17.7.02. There is no history of illness. The duration of the ailment not mentioned anywhere. The date of admission and date of discharge are noted and they are well within the policy. Ext. R6 is the copy of the medical certificate issued from PVS Memorial Hospital, Cochin shows there is no history of chronic liver disease in the past. The date of admission was 7.8.02 and date of discharge was 8.8.02 and both are within the policy period. The treated Doctor Vikraman was examined as RW1 and he deposed during cross examination that “      (In malayalam words)    .”

He also deposed that usually liver cirrhosis is seen to the persons those are using alcohol and those suffered from Hepatitis for 10 years. There is no document produced to show that the complainant was an alcoholic or a person suffered from hepatitis. History of illness not noted in any records.

 

            9. Ext. X-1 is the medical record from Jubilee Mission Hospital shows the nature of treatment given to the complainant during the period of 17.7.02 to 30.7.02. The pages 31 and 33 of Ext. X-1 show that diagnosis as Alcoholic Cirrhosis Liver. But there is no record to show that he had previous treatment for this disease. There is also no document to show that he had knowledge about the treatment alleged by the respondent. In the counter the respondent stated in detail that the insured was having Cirrhosis of liver with portal hypertension – diabetes. The different kinds of treatment given also stated in the counter and in Ext. X-1. But there is nothing to show that the complainant had availed treatment before the existence of the policy for a pre-existing disease. According to the respondent, the illness suffered by the complainant was a very chronic condition and years standing. The documents produced by the respondent show only the opinion of Doctors and there is nothing to show the knowledge or treatment of a pre-existing disease.

 

            10. The repudiation of the claim of the complainant shows deficiency in service on the part of respondent and the complainant is entitled for compensation also. The complainant claims Rs.33,046/- and there is no dispute regarding this amount. In the counter the respondent stated that there is no provision for interest for the claim amount. So the complainant is entitled for the medical expenses incurred along with compensation.

 

            11. In the result, the complaint is allowed and the respondent is directed to give Rs.33,046/- (Rupees thirty three thousand and forty six only) to the complainant and Rs.2500/- (Rupees two thousand and five hundred only) as compensation with cost Rs.500/- (Rupees five hundred only) within a month.