SRI. JIMMY KORAH (PRESIDENT) Complainant is a medi-claim policy holder of the opposite party. As per the schedule of the policy, complainant, his wife and mother are covered. The period of policy is 17.6.2004 to 16.6.2005. Mother of the complainant Anandavallyamma was admitted in P.S. Mission Hospital, Maradu from 14.6.2004 to 19.6.2004 and 21.8.2004 to 25.8.2004. But his claim was repudiated on the reason that there is a preexisting disease. Complaint alleged deficiency of service on the part of the opposite party. Hence he approached this Forum. 2. Opposite party filed version stating that there is no deficiency in service on the part of the opposite party. Period of policy is admitted. On perusal of back files of the complainant it is found that complaint availed benefit for the treatment for the very same disease of his mother on 22.4.2004. There is a previous policy from 16.5.2003 to 15.5.2004. Complainant has not disclosed previous disease while taking the present policy. Hence repudiation is justifiable. 3. Considering the rival contentions of the complainant and opposite party this Forum framed following issues:- a. Whether there is any deficiency of service on the part of the opposite party for fulfilling the contractual obligations and if so, what is the relief they are entitled? 4. Complainant produced 10 documents and marked it as Exts.A1 to A10. Opposite party produced 22 documents and marked it as Exts.B1 to B22. Complainant and opposite party given evidence. Complainant examined one witness. 5. On going through Ext.B1 (previous policy) and B3 (present policy) there is a break in between these two policies. Ext.B20 is the proposal form submitted by the complainant for the issuance of the policy in the disputed period. In this document the column for details of preexisting disease is blank. Argument of the opposite party is that since the present policy is not a continuing policy, so as per clause 4.1 is applicable in this case. The argument of the complainant is that B3a is the policy conditions of the present policy. As per clause 3 of this policy, occurrence of same illness after lapse of 60 days as stated above will be considered as fresh illness. We find force on this argument. Hence we reiterate the condition of the policy. “3.0.Any one illness will be deemed to mean continuous period of illness and it includes relapse within 60 days from the date of last consultation with the hospital/nursing home where treatment may have been taken. Occurrence of same illness after a lapse of 60 days as stated above will be considered as fresh illness for the purpose of this policy”. The only statement of the opposite party is that complainant received Rs.22,578/- on 22.4.2004 for the same disease. But no document produced to substantiate this contention. The only paper produced is Ext.B19 an investigation report of a private agency. A private agency can investigate and trace true facts. But for accepting their finding it should be supported with positive and reliable evidence and documents. In Ext.19 it is stated that Dr. Kunjumon Sebastian informed that Anandavally was first seen at hospital on 6.5.2004 and thereafter on 2.8.04. But no document produced from that hospital or doctor. Hence mere imagination of a so called private investigator cannot be relied and Ext.B19 has no value in evidence. If the complainant claimed any amount for the same disease as alleged by the opposite party then the treatment records have been submitted before opposite party. But this document was not produced before this Forum. If there are such documents, it is within the custody of the opposite party. Hence it can be concluded that story of early claim is a false story. The attitudes of the processing agency are seriously to be considered by the IRDA. Assuming that she was consulted on 6.5.04. The next consultation was on 2.8.04. This is after a lapse of 88 days. As per clause 3.0 relapse of a disease after 60 days can be a fresh illness. Hence repudiation of the claim is illegal. Regarding the claim amount opposite party has not resisted any objection. Hence claim of the complainant for an amount of Rs.9,516/- is allowable. Hence we find that there is a deficiency of service on the part of the opposite party. In the result, we allowed the complaint and directed the opposite party to pay Rs.9,516/- (Rupees nine thousand five hundred and sixteen only) with 6% interest from 21.3.2005 the date of repudiation. Since complainant has claimed only 6% interest. Complainant is also entitled to get cost of Rs.1000/- (Rupees one thousand only). Complaint allowed. Pronounced in open Forum on this the 30th day of May, 2008. Sd/- SRI. JIMMY KORAH: Sd/- SRI. K. ANIRUDHAN: Sd/- SMT. N. SHAJITHA BEEVI: APPENDIX:- Evidence of the complainant :- PW1 - G. Sunil Kumar (Witness) PW2 - Ajas (Witness) Ext.A1 - Policy Schedule Ext.A2 - Universal Health Insurance Policy – terms & Conditions Ext.A3 - Letter dated 7.12.2004 Ext.A4 - Photo copy of the letter dated 13.12.2004 Ext.A5 - Photo copy of the certificate dated 29.9.2004 Ext.A6 - Letter dated 6.1.2005 Ext.A7 - Photo copy of the registered letter dated 17.1.2005 Ext.A8 - Registered letter dated 13.1.2005 Ext.A9 - Copy of the Advocate notice dated 7.3.2005 Ext.A10 - Acknowledgement card Evidence of the opposite party:- RW1 - Jagakar Mallya (Witness) Ext.B1 - Individual mediclaim Policy Schedule for the period from 16.5.03 to 15.5.04 Ext.B1(a) - Mediclaim insurance policy rules and regulations Ext.B2 - Individual Mediclaim Policy Schedule for the period from 16.5.04 to 15.5.05 Ext.B2(a) - Mediclaim insurance policy rules and regulations Ext.B3 - Individual mediclaim Policy Schedule for the period from 17.6.04 to16.6.05 Ext.B3(a) - Universal health insurance policy rules and regulations Ext.B4 - Claim form dated 22.6.04 Ext.B5 - Discharge Summary 19.6.04 Ext.B6 - Claim form dated 31.8.2004 Ext.B7 - Discharge Summary dated 25.8.2004 Ext.B8 - Claim form Ext.B9 - Medical Certificate to be filled by the doctor treating the patient Ext.B10 series - Application etc. (5 pages) Ext.B11 - Registered letter dated 6.1.2005 Ext.B12 - Letter dated 13.1.2005 Ext.B13 - Advocate Notice Ext.B14 - Registered letter dated 21.3.2005 Ext.B15 - Claim form for revised mediclaim insurance policy Ext.B16 - Discharge Summary dated 30.9.04 Ext.B17 series - Mediclaim computation (4 pages) Ext.B18 - Certificate of Dr.Kunjummon M. Sebastian Ext.B19 - Letter dated 30.11.2004 Ext.B20 - Proposal form of Oriental Insurance Co. Ext.B21 - Postal receipt Ext.B22 - Copy of page No.154 of the postage book showing the sending o notice to the Advocate of the complainant. // True Copy // By Order Senior Superintendent To Complainant/Oppo.parties/S.F. Typed by:- pr/- Compared by:-
......................JIMMY KORAH
......................K.Anirudhan
......................Smt;Shajitha Beevi | | 
