By Smt. Padmini Sudheesh, President The case of the complainant is as follows: The complainant had taken a Medi-claim Insurance policy of the respondent vide policy No.100605/48/04/01098. The policy was taken in the year 2001. As per the terms of policy the respondent had agreed to reimburse all the expenses incurred for the treatment of a disease as mentioned in the policy. The sum insured is Rs.25,000/-. The complainant had a valid policy from 20/11/04 to 19/11/05. During the said period on 25/7/05, the complainant was admitted in Elite Mission Hospital, Koorkkenchery for treatment of Hernia. She was advised surgery by the Doctors of the said hospital and surgery was done. She was discharged on 30/7/05. She had the symptoms of Hernia six months before being admitted in the hospital. She had to spend Rs.14,913/- as hospital expenses and Rs.2,689/- as medicine charges, lab charges, ECG,X-ray charges. The complainant preferred a claim with the respondent. But the respondent rejected the claim as per letter dated 5/9/05 stating that the disease is a pre-existing one. The rejection of her claim is illegal and unjustifiable. Hence the complaint. 2. The version filed by the respondent is that : This respondent admits the policy for the period from 20/11/04 to 19/11/05. The mere existence of a policy does not ipso facto attach any liability with this respondent. The complainant has violated the terms and conditions of the policy. The claim of the complainant was rejected as ‘pre-existing’ as per clause 4.1 of the policy. According to the medical report of Dr.T.S.Mayooranadhan, the complainant was suffering illness six months prior to 21/7/05. Swelling and pain over the abdominal wall gradually increasing in size since about 6 months. The discharge certificate issued by the Elite Mission Hospital would also reveals the same fact. The fact as to the existence of the disease was suppressed by the complainant which is a violation of the terms and conditions of the policy. The complainant is not entitled for the hospital expenses with interest, the compensation for mental agony and costs. Hence dismiss. 3. The points for consideration are : 1) Is there any deficiency in service from respondent ? 2) If so reliefs and costs ? 4. The evidence consists of Exhibit P1, Exhibit R1 and Exhibits X1 to X8 and the oral testimony of PW1. 5. Points : According to the complainant she was taken the policy in the year 2004. She had a valid medi-claim policy from 20/11/04 to 19/11/05. On 25/7/05 she was admitted in hospital and a surgery was done for the treatment of hernia and discharged on 30/7/05. She had the symptoms of this disease just six months before being admitted in the hospital. So she is entitled for the reimbursement of treatment expenses and she applied for the claim. But the respondent rejected her claim stating the disease treated as a pre-existing one. In the counter the respondent admits that she had a valid policy from 20/1/04 to 19/11/05. But the treated disease is having a history of 6 months before the treatment. So they rejected the claim of the complainant as the complainant suppressed the existence of the disease. Exhibit P1 shows the policy period from 20/11/04 to 19/11/2005 and the policy inception date as 9/11/2001. The treated disease is within the policy period and the history of illness stated as 6 months before the treatment. The respondent rejected the claim as per clause 4.1 of the policy. As per Exhibit R1 the clause 4.1 says “All diseases/injuries which are pre-existing when the cover incepts for the first time”. Exhibit X8 the case sheet shows that the duration of present complaints as since about 6 months and the present complaint is not related to any pre-existing disease. The respondent rejected the claim upon the other significant past history which is filled by the treated doctor as Tubectomy 1982 – incisional Hernia developed there since 6 months. It is evident from Exhibit X8 that no other findings to show the pre-existence of the disease. In the oral testimony of PW1 she had admitted the tubectomy done in 1982. The treated doctor stated in Exhibit X8 that the incisional Hernia developed there since 6 months and also the treated doctor wrote in Exhibit X8 that the present complaint of disease is not related to any pre-existing disease. Exhibit X11 the discharge summary would also show that incisional hernia has developed there since only 6 months. It is definitely within the policy period. So the reason stated for the rejection of the claim by the respondent will not stand. The history of illness stated by the complainant is within the policy period and there is no suppression of pre-existence of the disease by the complainant. 6. The complainant is examined as PW1and during cross examination she deposed that she had the difficulties of Hernia since 2005 February and the policy was in existence from 2001 onwards. She also deposed that the present surgery was not the consequence of tubectomy. From the documentary evidence and from the oral testimony of complainant, it is eso the complainant is entitled to get compensation also. 7. In the result the complaint is allowed and the respondent is directed to pay Rs.17,602/-(Rupees Seventeen thousand six hundred and two only) to the complainant and Rs.2,500/- (Rupees Two thousand and five hundred only) as compensation with costs Rs.500/- (Rupees Five hundred only) within one month from the receipt of the copy of this order. If the amount is not paid within the stipulated time complainant will be entitled to get 12% interest for the amount of Rs.17,602/-. Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open Forum this the 12th day of May 2010.
| | [HONORABLE Rajani P.S.] Member[HONORABLE Padmini Sudheesh] PRESIDENT[HONORABLE Sasidharan M.S] Member | | 
