By Smt. Padmini Sudheesh, President: The facts of the case are as follows. Second petitioner is the wife of Late Kochappu and others are the children. Sri. Kochappu died on 6.10.01. First petitioner was the only complainant and others were impleaded later. Late Kochappu was a member of P.D.D.P. Society, Kombodinjamakkal and it is a milk society. For the benefit of the members, a group mediclaim policy vide No.101100/48/46/11/45123/00 was introduced and Late Kochappu was also made a subscriber by paying the premium. The said Kochappu died on 6.10.01. He was suffered from Jaundice and died at Mother Hospital, Thrissur. Till his death he was so healthy. After death, the petitioners claimed for the policy benefits, but it was repudiated as per letter dated 19.3.02. The reason for repudiation stated that he was died due to a disease, which was pre-existing and not of a recent occurrence. This allegation is baseless. There is deficiency in service. Lawyer notice sent, but no reply and remedy so far. Hence this complaint. 2. The counter of the Insurance Company is as follows: The limit of liability of this respondent is as per the terms, conditions, and exception of the policy. As per the policy conditions, this respondent is not liable to make any payment under this policy in respect of any such expenses whatsoever incurred by any insured person in connection with or in respect of such diseases, which has been in existence at the time of proposing the insurance. Pre-existing condition means any sickness or its symptoms, which existed prior to the effective date of this insurance whether or not the insured person had knowledge that the symptoms were relating to the sickness. Complication arising from pre-existing disease will be considered part of that pre-existing condition. This respondent repudiated the claim of the petitioners on 19.3.02 since the disease was a pre-existing one and not of a recent occurrence. No deficiency in service is committed by this respondent. Hence the above claim is not maintainable and is to be dismissed with costs. 3. The respondent also filed additional version. In the additional counter it is stated that now this policy witnesseth that subject to the terms, conditions, exclusion and definition contained herein or endorsed or otherwise expressed hereon, the company undertakes that if during the period stated in the schedule or during the continuance of this policy by renewal, any insured person shall contract any disease or suffer from any illness thereinafter called disease or sustain any bodily/injury through accident and such insured person require upon the advice of duly qualified physician/medical specialist/medical practitioner or of a duly qualified surgeon to incur expenses for medical/surgical treatment at any nursing home/hospital in India as here in defined as any inpatient or on domiciliary treatment in India under Domiciliary Hospitalisation Benefits as hereinafter defined, the company will pay to the insured person the amount of such expenses as are reasonably and necessarily incurred in respect of thereof by or on behalf of such insured person but not exceeding in any one period of insurance the sum insured of Rs.5000/- under any or all heads of expenses mentioned below: (A) Room, boarding expenses as provided by the Hospital/nursing home. (B) Nursing expense. (C) Surgeon, anaesthetist, medical practitioner, consultants, specialist fees. (D) Anaesthesia, blood, oxygen, operation theatre charges, surgical applicants, Medicines and drugs, diagnostic materials and x-rays, dialysis, chemotherapy, Radiotherapy cost of pacemaker artificial limbs and cost of organs and similar Expenses. It is also stated that companys liability in respect of all claims admitted shall not exceed the sum insured of Rs.5000/-. 4. The points for consideration are: (1) Is there any deficiency in service? (2) Whether the petitioners are entitled for the policy benefits? (3) Reliefs and costs. 5. The evidence consists of Exts. P1 to P3 and Exts. R1 to R5. 6. Point No.1: The first point to be considered is the deficiency in service. The policy holder Sri. Kochappu expired on 6.10.01. The reason stated as per Ext. R2 and R3 is acute severe Pancreatitis, Renal failure and Bronchial Asthma. As per Ext. R2 he was admitted on 26.9.01. The policy period was 23.3.00 to 22.3.02. The consultation was within the period of insurance. There is no other document stating the consultation or treatment by a doctor for the same disease to the insured. Even if the insured was suffering from a longer period, absence of records showing the previous consultation and treatment make the claim genuine. Here no document showing that he had been previous treatment. Hence the petitioners are entitled for the insurance benefits. As per the policy, the claim is limited up to Rs.5000/- only. Hence the petitioners are entitled for Rs.5000/- towards the medical expenses. 7. Points-2 and 3: Repudiation of a genuine claim is a deficiency in service on the part of the respondent Company and the petitioners are entitled for compensation of Rs.2000/-. 8. In the result, the complaint is allowed and the respondent is directed to pay Rs.5000/- (Rupees five thousand only) as the insurance benefit; Rs.2000/- (Rupees two thousand only) towards compensation and Rs.1000/- (Rupees one thousand only) as costs. Comply the order within a month. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 4th day of August 2008.
