By Smt. Padmini Sudheesh, President<br /> <br /> The case of the petitioners in brief is as follows:<br /> <br /> The 1st complainant was a policy holder of the respondent under the Pravasi Suraksha + Kudumba Arogya Scheme for the period from 28/3/02 to 27/3/07. As per the policy conditions 2nd complainant also included in the purview of the policy. During the policy period 2nd respondent had undergone treatment for Mild Coronary Artery Disease, Degenerative Complete Heart Block in Amrita Hospital, Cochin. He was admitted on 5/1/03. At the time of joining the policy there was no such disease. He had incurred medical expense of Rs.69574/-. He had applied for the policy benefits, but was rejected stating that the 2nd complainant is a diabetic for past 10 years. The heart disease is not because of the diabetic complaint of the 2nd respondent. He had been treated for the diabetic disease even 10 years before 2003. At the time of taking the policy he had no such disease at all. Hence repudiation of the claim on that basis is a deficiency in service of the respondent. Hence this complaint.<br /> <br /> 2.The version in brief is as follows: The allegation in the petition that the disease diabetic mellitus of the 2nd complainant was cured in the years 1996 is utter false and denied. The discharge summary submitted by the complainants to the respondent shows that the 2nd complainant aged 63 years is a diabetic for past 10 years. He was diagnosed to have complete heart block with broad ORS escape. He was a diabetic patient for the past 10 years and the first complaint, the proposer of the policy has not disclosed these cronic disease in the proposal form submitted. The policy of insurance is basically a contract between the parties. The proposal contains the following declaration which makes the policy invalid in the event of any misrepresentation by insured. The act of complainant is deceiving, consciously suppressing the disease. The amount of compensation claimed is highly excessive. The complaint is vexatious. Hence dismiss.<br /> <br /> 3. The points for consideration are :<br /> 1) Is there any deficiency in service ?<br /> 2)If so whether the complainants are entitled for the policy benefits?<br /> 3) Reliefs and costs ?<br /> <br /> 4. The evidence consists of Exts. P1 to P4 and Exts. R1 to R12.<br /> <br /> 5. Point No.1 : The claim of the complainants has been repudiated by the Company. In the counter it is stated that the 2nd respondent was a diabetic patient for the last 10 years and it was suppressed in the proposal form. In the proposal form there is specific question regarding this aspect. But he has answered ‘no’ to all the questions. In the counter, the company has stated that the complainants suppressed the disease of diabetic mellitus. In the complaint para 2 it is admitted that he was a diabetic patient before 10 years of 2003. It is also added that he has treated for the disease and completely recovered. Admission which is the best evidence affirms that he was a diabetic patient as stated by the company. So there is willful suppression of material facts. But the question to be considered is whether the heart disease is the outcome of diabetic mellitus. The petitioner is claimed for the expenses incurred for the heart disease. Exhibit P4 is a crucial document in this regard. Exhibit P4 is issued by a cardiologist in Amrita Institute of Medical Science. The Exhibit P4 certificate shows that the diabetic antecedents are not in any way connected with the heart disease for which he underwent treatment from their institute. So it is clear that the heart disease is not the outcome of diabetic mellitus. The consultation and treatment are within the policy period also. So the complainants are entitled for the benefits of the policy. The quantum of amount stated is Rs.69,574.12 for the complainant. The company has no case that he is not entitled for the amount. Exhibit P3 describes the expenses. In the policy no limit is prescribed. Hence he is entitled for that amount. Repudiation of a genuine claim is a deficiency in service on the part of the company.<br /> <br /> 6. In the result the complaint is allowed and the respondent company is directed to provide Rs.69,574/- (Rupees Sixty nine thousand five hundred and seventy four only) to the 2nd complainant with 12% interest from 13/5/03 till realization. No order as to cost and compensation. Comply the order within one month.<br /> <br /> Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open Forum this the 7th day of August 2008. <br />