<br /> <br /> By SRI.K. VIJAYAKUMARAN ACHARY, PRESIDENT.<br /> <br /> Complainant for realization of policy amount under Pravasi Suraksha Kudumba Arogya Policy.<br /> <br /> The averments in the complaint can be briefly summarized as follows:<br /> <br /> The complainant had purchased Pravasi Suraksha Kudumba Arogya Policy No,760902470080150 from the opp.party on 5.10.2000 which is valid upto 4.10.2005. The policy coverage is extended to the 2nd complainant who is the mother of the 1st complainant. The 2nd complainant suffered Coronary Artery Disease and she was admitted in Sree Chtra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram. The 2nd complainant was admitted in hospital from 30.4.2002 to 6.5.2002. The Doctors advised Bye pass surgery and she was admitted again on 29.1.2003 and surgery was conducted on 2.2.2003 and she was discharged on 101.2.2003. The complainant preferred a claim but the same was repudiated by the office on the ground that the 2nd complainant was suffering from pre-existing disease which was excluded from the purview of policy conditions. The contention of the opp.party is that the 2nd complainant was suffering from diabetes and hypertension which existed for the last 12 years and which is a pre existing disease and which resulted into the coronary Artery Disease is not tenable. The coronary Artery Disease is not direct and natural outcome of the of the diabetes and hypertension. And the same are neither a pre-existing disease nor a pre existing condition leading to coronary artery disease. The complainant suffered on account of deficiency in service on the part of the opp.party. Hence the complaint.<br /> <br /> <br /> <br /> <br /> The opp.party filed a version contending, interalia, that the complaint is not maintainable either in law on or facts. The complainant is approached the Forum suppressing the material facts regarding the case. The definition complaint, complainant, Consumer Dispute service as defined in section 2 [1 of the Consumer Protection Act do not cover the claim madeout in the complaint. This opp.party has issued a Pravasi Suraksha Kudumba Arogya Policy to the complainants for a period from 5.10.2000 to 4.10.2005. The policy was issued on the basis of the enrollment form submitted by the 1st complainant for himself and on behalf of the 2nd complainant. The policy was issued on the basis of the particulars furnished in the enrolment form as per the specific conditions in the exclusion clause of the policyh, the opp.party shall not be liable to make payment under the scheme in respect of expenses incurred by the insured persons in connection with the disease which have been in existence at the time of proposing for the insurance. The 1st complainant as per letter dated 18.9.2002 informed the office that the second complainant was hospitalized at chithira Thirunal Institute of Medical Science and Technology in connection with treatment of heart ailment from 30.4.2002 to 6.5.2002 and sought for reimbursement of medical expenses. As per the medical records produced by the complainant, the 2nd complainant was a known hypertensive and diabetic patient for last 12 years and she developed chest pain with radiation to both arms and sweating on 30.4.2002 for which she was treated from 20.4.2002 to 6.5.2002. It is also stated in the case summery and case record that patient had the family history of coronary Artery disease.. Even in the enrolments form submitted by the first complainant it is stated that the 2nd complainant was suffering from ailment like diabetes, blood pressure and heart ailment etc. The medical policy opinioned that diabetes and hypertension are alterable coronary risk factors . Since the claim preferred by the complainant case within the purview of the exclusion of the policy the claim was repudiated. The complainant has no cause of action against the opp.party since there is no deficiency in service on the part of the opp.party. Hence the opp.party prays to dismiss the complaint.<br /> <br /> Based on the contention the points arise for consideration are:<br /> <br /> [1] Whether there is deficiency in service on the part of the opp.parties<br /> [2] Reliefs and costs.<br /> <br /> <br /> <br /> For the complainant PW.1 is examined. Ext.P1 to P8 are marked.<br /> <br /> For the opp.party DW.1 is examined. Ext. D1. to D8 are marked.<br /> <br /> <br /> <br /> Points [i] & [ii]<br /> <br /> The complainant has taken Pravasi Kudumba Arogya Policy from the opp.party under which insurance coverage was extended to the 2nd complainant who is his mother. The 2nd complainant was admitted in the Sree Chithra Thirunal Institute of Medical Sciences and Technology on 30.4.2002 when she undergone treatment as an impatient upto 6.5.02 for which he incurred an expenditure of Rs.15690/- evidence by Ext.P3. and a claim was submitted as Ext.D2. It is the further case of the complainant that his mother underwent bye pass surgery on 2.2.2000 for which she was admitted on 29.1.2003 and was discharged on 101.2.2003 and a sum of Rs.74,753/- was expended towards treatment charges evidenced by Ext.P4. The grievance of the complainant is that the opp.party has repudiated the claim on the ground that the 2nd complainant was suffering from pre existing disease and under the exemption clause No.1 she is not entitled to get the claim<br /> <br /> There is no dispute that the 2nd complainant underwent treatment for coronary Artery disease at the Sree Chitra Thirunal Institute of Medical Science and Technology, Thiruvananthapuram. It is an admitted fact that the 2nd complainant was suffering from Hypertension and Diabetics at the time when the policy was taken and this fact was disclosed in the application. <br /> <br /> The learned counsel for the opp.party would argue that hyper tension and Diabetics are alternate factors for coronary artery disease and the policy coverage is not applicable to pre existing diseases and disease arising out of pre existing conditions. According to him in Ext.D7 the Doctor who treated the 2nd complainant has reported that Diabetics and hypertension an alterable coronary risk factors and patients with these disordering are more likely to get coronary artery diseases and that the coronary artery disease was present with the 2nd complainant for some years which has manifested as chest pain only on 30.4.2002. So according to him coronary artery disease developed by the 2nd c complainant is a complication arising from pre existing diseases of diabetics and hypertension which existed about 12 years and in support of his contention he has relied on the medical authority the Harrisons principles of internal Medicines Volume I and II.<br /> <br /> The learned counsel for the complainant argued that the burden to establish that the coronary artery disease is the out of Diabetics and hypertension are on the opp.party which they fail to discharge. According to her the doctor who issued Ext.D7 does not conclusively say that the coronary artery disease developed by the 2nd complainant is due to the hypertension and diabetics but say that the patients with these diseases are more likely to get coronary artery disease. These doctors were also not examined to establish that coronary artery disease is one arising out of pre-existing hypertension and diabetics. The decisions and the books relied on by the learned counsel for opp.party would go to show that the risk factor heart diseases in patients with diabetics and hypertension are high but they does not conclusively say so. From the available evidence it cannot be concluding said that the presence of diabetes and hypertension are the sole reason for developing coronary artery disease in the 2nd complainant.<br /> <br /> The complainant has disclosed that the 2nd complainant is suffering from diabetics and hypertension when the policy was taken and there is no suppression. The opp.party could have refrained from issuing policy to the 2nd complainant. After issuing the policy the opp.party cannot now say that the coronary artery disease is due to pre-existing diabetics and hypertension.<br /> <br /> Ext. D4 is the request made by the complainant seeking reimbursement of expenses received for the treatment of 2nd complainant for the period from 30.4.2002 to 6.5.2002 and Ext.D2 is the claim form and the claim was repudiated by the opp.party as per Ext.D8. Though the complainant would claim certain other amounts also no claim is seen preferred in respect of those amounts. The required certificate in respect of those claim are also not produced.<br /> <br /> For all that has been discussed above we hold that the repudiation of the claim of the complainant is not proper and that there is deficiency in service on the part of the opp.party. Point found accordingly.<br /> <br /> <br /> <br /> <br /> <br /> In the result the complaint is allowed in part directing the opp.party to pay to the complainant Rs.15,650/- with interest @ 9% per annum from 15.11.2002till payment and Rs.2500/- as compensation and costs. The order is to be complied with within one month from the date of receipt of this order.<br /> <br /> <br /> <br /> <br /> Dated this the 26th day of April, 2008.<br /> <br /> <br /> <br /> <br /> I N D E X<br /> <br /> List of witnesses for the complainant<br /> PW.1. - Shihabudeen<br /> <br /> <br /> List of documents for the complainant<br /> P1. – Power Attorney holder<br /> P2. – Insurance certificate<br /> P3. Receipt<br /> P4. - Bill for Rs.15690/-<br /> P5. – Hospital bill for Rs.73,353/-<br /> P6. – Advocate notice<br /> P7. – Reply notice<br /> P8. Bill dated 21.1.2003.<br /> <br /> <br /> List of witnesses for the Opp.party<br /> DW.1. – R. Rudran Nair<br /> <br /> <br /> List of documents for the opp.party<br /> D1. – Policy with conditions<br /> D2. – Claim form<br /> D3. –Medical Certificate<br /> D4. – Letter of Reimbursement for medical treatment<br /> D5. – Letter send by opp.party to Dr. M. Sasikumar, Cardiologist, Kollam<br /> D6. - Letter sent by Dr. M. Sasi kumar, Consultant cardiology to the opp.party<br /> D7. – Letter sent by opp.party to Dr. Sasikumar, Cardiologist, Kollam.<br /> D8. – Claim on Pravasi Suraksha Kudumba Arogya Policy <br /> <br />