By Sri. K. Gheevarghese, President:

The complaint filed under section 12 of the Consumer Protection Act 1986.

The facts led to the complaint in brief is as follows:- The Complainant availed a mediclaim policy from the 1^st Opposite Party and the 2^nd Opposite Party acted as an agent of it. The coverage of the policy was from 14.3.2007 to 13.3.2008. The risk covers the amount of Rs.1,05,000/- as the sum assured by the insurer.

2. The Complainant had undergone treatment for chest discomfort on 13.1.2008 and later on the same day he was transferred and had undergone treatment at MIMS Hospital Kozhikode. The treatment for the Complainant was for ST elevation myocardial infarction, old inferior wall myocardial infarction double vessel coronary artery disease, ventricular dysfunction and diabetics mellitus type 2. The Complainant was given treatment and he was discharged from the MIMS Hospital on 19.1.2008. Again on the 2^nd time the Complainant was admitted on 21.1.2008 in the same hospital and had undergone treatment and discharged on the same day and was advised the Complainant for treatments afterwards. The treatment of the Complainant had the expenses of Rs.1,42,549/- in the MIMS hospital other medical expenses of Rs.5,356/-. On the date of discharge Rs.1,772/- was also paid by the Complainant towards the charge of treatments. The 1^st Opposite Party is the insurer who is legally liable to compensate the Complainant the amount assured for the medical treatments. The Opposite Party in contrary repudiated the claim of the Complainant on the ground that the Complainant had pre-existing disease which was suppressed. The repudiation on this ground is absolutely illegal and the same is a deficiency in service on the part of the Opposite Party. There may be an order directing the Opposite Parties to:-

(a) Pay the sum assured along with cumulative bonus of the mediclaim policy No.101601/48/

06/20/00002750 to the Complainant with interest.

(b) Pay a sum of Rs.25,000/- towards the cost and compensation along with other reliefs

found to be deemed fit.

3. The Opposite Party filed version contenting the claim of the Complainant. The sum up of the version is as follows:- The Complainant is a known case of coronary artery disease old inferior wall (M1) (1990) and known diabetic patient before the commencement of the risk. The Complainant had pre-existing disease which was not disclosed instead it was kept suppressed and that is against the terms of policy. There is no deficiency in service on the part of the Opposite Party. The Complainant is not entitled for the cumulative bonus of the mediclaim with interest along with cost and compensation, the complaint is to be dismissed with cost to the Opposite Party.

4. The points in consideration are:

1. Whether the repudiation of the claim of the Complainant amount to deficiency in service.

2. Relief and cost.

    

5. Point No.1:- The Complainant filed proof affidavit, Ext. A1 to A5 are marked. The Opposite Parties filed proof affidavit interalia contenting the allegation of the Complainant, Ext.B1 to B4 and Ext.X1 series are marked. The case of the Complainant is that the Opposite Party repudiated the claim of the Complainant to reimburse the medical expense covered in the risk of insurance by the Opposite Party. Whereas the Opposite Party contented that the claim was repudiated on the ground of preexisting disease, which was suppressed and not disclosed when the insured got access into the policy. The major aspect which is to be taken into consideration whether the Complainant suppressed the fact of pre-existing disease when he

got access into the policy. Ext.X1 series which are three in numbers are the case sheet of the referred hospital MIMS Hospital, Calicut. The treatment of the Complainant in three period comprises the Ext.X1 series. In the history of patient illness in Ext.X1 series disclosed that the Complainant has myocardial infraction since 1990. The Ext.B2 is the certificate issued by consultant cardiologist in MIMS Hospital, Calicut in this certificate the probable date of commencement or manifestation on the history of illness is recorded as 1990. The Complainant is having the known case of coronary artery disease and old inferior wall myocardial infarction in 1990. From these documents it is to be considered that the Complainant when got access into the policy had been under treatments for cardiac complaint since 1990. At the time of his access into the policy the Complainant had the diabetic complaint that too was also not disclosed. From the very aspect of this it is to be considered that the repudiation of the policy on the ground suppression of the existing disease cannot be interfered and it does not amount to deficiency in service. The repudiation of the claim is reasonable and the point No.1 is found accordingly.

6. Point No.2:- The Complainant had not disclosed the existing disease at the time of his inception to the policy. The Opposite Party has not done any deficiency in service. The detail discussion of point No.2 does not arises. In the result the complaint is dismissed, no order as to cost.

Pronounced in open Forum on this the day of 30^th April 2009.

PRESIDENT: Sd/-

MEMBER- I : Sd/-

MEMBER-II: Sd/-

A P P E N D I X

Witnesses for the Complainant:

PW1. Parameswaran Complainant.

Witnesses for the Opposite Party:

OPW1. M. Pradeep Kumar Manager, United India Insurance Company, Kalpetta.

Exhibits for the Complainant:

A1.(3 sheets) Individual Mediclaim Policy

A2. Discharge Summary.

A3. Discharge Summary

A4.series. Pharmacy Bill

A5. Copy of Claim Status dt:22.03.2008.

Exhibits for Opposite Party:

B1. Copy of Mediclaim Proposal. dt:09.03.2006.

B2. Medical Certificate.

B3. Discharge Summary.

B4. Discharge Summary.

X1 Series. Case Sheet.