The complainant joined in a Pravasi Suraksha Kudumba Arogya Poicy with the respondent company vide certificate No.2000/47/760300/80199(760300). The period of the policy was from 20/3/2000 to 19/3/2005. The complainant has undergone treatment for the disease Cervical Spondylosis in Jubilee Mission Hospital. The period of treatment was from 12/8/02 to 17/8/02. He was working in abroad and reached in India on 4^th May 2002. Subsequently he had left the place and due to the disease he again reached the country and Rs.8,823.70 was incurred as treatment expenses. After that he applied to the company for insurance claim. But it was not honoured by the company. The complainant is also entitled to get Rs.15,000/-, the fare of flight ticket. The complainant sent lawyer notice to the respondent by seeking remedy. But the claim is not honoured so far. Hence the complaint.

 

            2. The counter is that the respondent company issued a policy viz., Pravasi Suraksha Kudumba Arogya scheme in favour of complainant and their children subject to the terms and conditions. The effective date of the policy is from 20/3/00 to 19/3/2005. The respondent denied the allegation that the complainant is eligible to get expenses for the alleged treatment and travelling expenses. He has to prove that he has come to India only for the purpose of treatment as alleged in the petition. In this case the complainant has suppressed the material facts regarding the pre-existing of disease from the respondent and he fraudulently obtained the certificate. So this respondent has no liability to pay any amount. As per records submitted by the complainant it is seen that the complainant was admitted in Jubilee Mission Hospital on 12/8/02 for investigation of giddiness. MRI and other investigations were done and the doctor has diagnosed as a case of Hypertension Diabetics and Cervical spondylosis and all these are of very chronic in nature and the symptom related to them are created before the effective date of the policy. As per Clause 7(1) of the exclusion in the policy the company shall not be liable to make payment under the scheme in respect of expenses what so ever incurred by as far any insured person in connection with or in respect of such diseases which have been in existence at the time of proposing this insurance. Pre-existing condition also means any sickness or its symptoms which existed prior to the effective date of the insurance whether or not the insured person has knowledge that the symptoms were relating to the sickness. Complication arising from pre-existing disease will be considered as a part of that pre-existing condition. The complainant   was purposefully suppressed the material facts from the insurance company. In the light of the evidence of our investigation which is also confirmed by the doctor that the disease is a pre-existing one this respondent has no liability to pay any amount. Hence dismiss the complaint.

 

            3. Points for consideration are:

1) Is there any deficiency in service?

2) If so reliefs and costs?

 

            4. The evidence consists of Exhibits P1 to P3 on the part of complainant and Exhibits R1 to R12 from the part of respondent. No oral evidence adduced by both.

 

            5. Points : The complaint is filed to get reimbursement of medical expenses incurred to the complainant. According to the complainant he was a Pravasi Suraksha Kudumba Arogya Policy holder of respondent and he has undergone treatment for the disease within the policy period and he is entitled to get medical expenses incurred to him. The respondent stated that the complainant is not entitled for any relief since the disease for which he was treated was a pre-existing disease. So according to them there is suppression of material facts and the complainant is not entitled for any relief. The respondent produced Exhibits R1 to R12 to substantiate their case. Exhibits R4 to R7 are the treatment records and would show that the treatment was in the year 2002. The effective date of policy is from 20/3/2000 to 19/3/2005. As per these Exhibits it cannot say that he has got pre-existing disease.

 

           6. The contention of respondent is that the claim was repudiated on the ground of pre-existence of disease. Exhibit P1 is the letter sent by respondent company to the complainant by intimating their inability to consider the settlement of claim. It is stated that the claim is not admissible as per condition 7(1) of Pravasi Suraksha Kudumba Arogya Scheme. Both of them did not produce the policy terms and conditions. We are unaware of the condition 7(1) of the policy. In the counter the respondent stated that only due to pre-existence of disease they dishonoured the claim. They produced Exhibit R8, a certificate issued from Al Rafa Poly Clinic. It is stated in this document that the complainant was found to have chronic sinusitis and sprain neck for which he was started on medication with relief. The document is dated 5^th August 2002. It was well within the policy period. But there is no explanation to the word chronic. And no period specified that how long he was suffering from the said disease. Exhibit R9 is another certificate produced by the company issued by Dr.P.V.Francis. It is certified by him that all these diseases are of very chronic nature and symptoms related to them might be pre-existing at the effective date of this policy. He is not sure about the pre-existence and it may be noted that the word used by him is “might be”. The doctor is not summoned by the respondent to prove the version. So the words of the certificate alone cannot be taken into evidence. There is no document to show that the complainant has undergone treatment for the said disease before the policy period. There is also no document to show that the complainant has prior knowledge about the suffering of the disease. Since there is absence of evidence regarding the prior consultation with the doctor or prior treatment it is unable to believe that he has got disease before the policy. So the complainant is entitled for the expenses incurred for the treatment.

 

            7. The complainant put a prayer for return of the flight ticket charges. According to him he had travelled from abroad to India for the treatment of these disease. But there is no evidence to show that he had travelled for the treatment and there is no evidence at all to show that he had travelled at the relevant time. So he is not entitled for the amount sought for the air ticket.

 

            8. In the result the complaint is allowed and the respondent is directed to pay Rs.8,823.70/- (Rupees Eight thousand eight hundred twenty three and paise seventy only) to the complainant with interest at the rate of 12% from the date of complaint till realization with cost Rs.500/- (Rupees Five hundred only) within a month from the date of receipt of copy of this order.