The case of complainant is that the complainant was a policy holder of respondent vide policy No.470/2000. On 23.2.2000 he was admitted in Aswini Hospital for liver treatment and discharged on 24.2.2000. Before that the treatment was commenced on 20.1.2000. Subsequently he had applied for the insurance claim with all relevant documents, but was rejected by the Company. The reason stated for rejection of the claim is incorrect. The complainant had produced medical bills of Rs.8175.34 to the company. On 9.2.2001 a lawyer notice was issued. The rejection of claim shows deficiency in service on the part of respondent. Hence this complaint.

 

            2. The counter is as follows: This respondent admits that the complainant has medical insurance policy subject to the terms and conditions. The period of the policy is from 22.2.1999 to 21.9.2000. The complainant has suppressed the fact that he was suffering from the alleged illness long before he had taken the policy. Nowhere in the complaint the complainant has stated the name of the hospital and the name of the doctor who treated him. The medical expenses shown are not correct. On getting the said claim this respondent adopted to regular procedures of investigation. According to the investigation report and the documents collected by this respondent the complainant was suffering from some medical problems connected with liver from childhood itself. He was under treatment at the Guruvayur Devaswom Medical Centre before taking the policy for liver complaints. The test report dated 18.12.99 obtained by the complainant from Sudharma Laboratory showing Serum Bilirubin level at 1 mg% as against the normal value of less than 1 mg%. The Serum GPT at 74 as against the normal value of upto 42 proves this. As per Dr. P.V. Antony’s report the complainant’s disease was pre-existing and was using medicine for a long period. These are the reasons for rejecting the claim. The complainant has suppressed these material facts. Hence the complaint is bad for suppression of material facts. The claim of complainant is not entertainable as per the policy exclusion No.4.1. The complainant has no cause of action against this respondent. Hence dismiss the complaint. 

 

            3. The points for consideration are:

(1)   Is there any deficiency in service on the part of respondent?

(2)   If so, reliefs and costs.

 

            4. The evidence consists of Exts. R1 to R17, Ext. X-1 and X-2 series and the statement of RWs-1 and 2.

 

            5. Points-1 & 2: The case of complainant is that he was a policy holder of respondent vide policy No.470/2000 and he was admitted in Aswini Hospital on 23.2.2000 for liver illness and treated there and discharged on 24.2.2000. He had incurred Rs.8175.34 as medical expenses and he applied to the Company for medical reimbursement benefit. But was rejected by the Company and the reasons stated is not correct. So he filed this complaint to get the treatment expenses and compensation.

 

            6. In the counter the respondent company stated that the claim of complainant is not entertainable as per the policy exclusion clause No.4.1 which says “such diseases which have been in existence at the time of proposing this insurance are exempted from the payment of policy benefit. So the claim of the complainant was rejected by the respondent by stating pre-existence of disease.

 

            7. According to the complainant, he was treated for one day in the Aswini Hospital for liver treatment. The period of treatment was from 23.2.2000 to 24.2.2000 and was within the coverage of policy. The period of the policy as admitted by the respondent and was from 22.9.1999 to 21.9.2000. There is no dispute regarding this aspect. Ext. X-1 is biochemistry report from Sudharma Laboratory. The name of patient stated as Ajaykumar. The test report dated 18.12.98 shows Serum Bilirubin level and Serum GPT etc. as above the normal value. So according to the respondent the complainant was suffering from liver complaint before the policy. The complainant challenged this Ext. X-1 document and the Doctor who has issued this certificate was examined as RW1 and stated that what is stated in her certificate is true. She deposed that Serum GPT is more than the normal range and Serum Bilirubin is also more than the normal level. During cross-examination she was asked about the patient’s name and she said that as per Ext. X-1 report it cannot be said “Ajaykumar stated in the report and the complainant are the same”. RW1 the doctor further stated that “(X-1                  (in Malayalam words)              .”                          In Ext. X-1 the name of patient simply stated as Ajaykumar. There is no address and not even initial at all. Since there is dispute regarding the genuineness we cannot rely fully the document of Ext. X-1. It is a doubtful document and cannot say that the complainant and the Ajaykumar stated in Ext. X-1 are same. 

 

            8. Ext. R6 is a certificate issued by RW2 and stated that complainant was treated for chronic Hepatitis. Fatty liver. He also certified that he considers it is a pre-existing disease. The doctor is examined as RW2 and during chief examination he confirmed the facts stated in Ext. R6 certificate. During cross-examination the Counsel for complainant asked about the records verified by him for issuing Ext. R6 certificate. There are no such details. RW2 simply stated that Mr. Ajaykumar Mediclaim Policy No.470/2000 treated for chronic hepatitis fatty liver. According to him he considers it is a pre-existing disease. The certificate expresses his opinion only and it is not an authoritative certificate to prove that the complainant was suffering from liver disease. He has no information about the commencement of the disease. The records relied by him to arrive at such a conclusion are not noted. He admitted during examination that he did not see the patient directly and did not treat him. He simply issued this certificate. According to us only to support the respondent company he issued such kind of certificate without any records. Because in the certificate he stated that “in my opinion it comes under Exclusion No.4.1 and it is not advisable to get the claim.” He deposed that he is not a panel doctor of the company. It is not at all expected from doctors who are not in the panel of company to state these kinds of comments in the certificate. So we are not in a position to accept the contents of Ext. R6. 

 

            9. Another point stated by the respondent is that the complainant was under treatment at the Guruvayur Devaswom Medical Centre before taking the policy. But there is no document produced from the Devaswom Hospital to prove this. Ext. R17 report of Investigator shows that the investigator had consulted doctors of Guruvayur Devaswom Medical Centre. In the report it is stated that the investigator made request for details of the treatment undergone by the complainant and were not obtained. Anyway no documents submitted by the investigator to the company to show that the complainant had prior medical problems relating to liver. So the rejection of claim of the complainant by the respondent shows deficiency in service and he is entitled to get the medical expenses incurred to him. The medical expenses claimed by the complainant are Rs.8175.34. Ext. X-2 series contains the details of medical bills of the same amount and the complainant is entitled to get the amount. Since there is rejection of a genuine claim on the part of respondent, the complainant is entitled to get compensation also.

 

            10. In the result, the complaint is allowed and the respondent is directed to pay Rs.8175.34 (Rupees eight thousand one hundred and seventy five and paise thirty four) as medical expenses and Rs.3000/- (Rupees three thousand only) as compensation with cost Rs.500/- (Rupees five hundred only) to the complainant within a month. If the amount is not paid within the prescribed period the complainant is entitled to get interest for the amount of Rs.8175.34 at the rate of 12% till realisation.