By Sri. K. Gheevarghese, President:
The complaint filed under section 12 of the Consumer Protection Act 1986.
The complaint in brief is as follows:- The Complainant had undergone treatment at Baby Memorial Hospital, Calicut referred from Jyothi Hospital, Mananthavady for pain and swelling in right leg. The treatment given to the complainant was as an inpatient and it continued from 19.9.2008 to 02.10.2008. The Complainant is insured by the Opposite party in the “Ksheera Karshaka Arogya Sureksha Padhathi” and the premium of Rs.378/- was given. The treatment from the hospital caused heavy expenses. Towards the claim of Rs.34,000/-. The application was forwarded to the Opposite Party but it was rejected on the ground of pre-existing disease. The reputation of the claim is absolutely a deficiency in service. The claim of the Complainant for Rs.34,000/- is reasonable and based on genuine grounds. There may be an order directing the Opposite Party to give the Complainant Rs.34,000/- with the interest at the rate of 18% along with the compensation of Rs.10,000/- to the Complainant.
2. The Opposite Party filed version and in short it is as follows. The policy of the Complainant and the inception to the scheme is admitted by the Opposite Party. The scheme envisages benefits to 13440 diary farmer families and members in Malabar Regional Co-operative Milk Society covering the period from 01.07.2008 to 30.6.2009. The risk covers of the policy is for hospitalization expenses and death whereas the benefit of the scheme does not extent to the insurer who is having pre-existing disease and the treatment of the same. The treatment availed by the Complainant is in connection with the pre-existing disease of diabeties mellitus, abscces leg, hypertension and copd. The claim of the Complainant was processed and repudiated on the ground that the Complainant contracted with the pre-existing disease. The repudiation of the claim is not having any deficiency in service. The complaint is to be dismissed with cost to the Opposite Party.
3. Points in consideration are:- Is there any deficiency in service on the part of the Opposite Party? Relief and cost.
4. Points No.1 and 2:- Points No.1 and 2 can be considered together. The Complainant filed proof affidavit, Ext.A1, B1 and B2 are marked through the Complainant. Ext.B3 to B5 are the documents produced by the Opposite Party. Both the Complainant and Opposite Party have given oral testimony in this case.
5. The case of the Complainant is that though insured under a scheme, the Opposite Party is not ready to give the Complainant the amount claimed for the treatment and the expenses of operations held from Baby Memorial Hospital, Calicut. The repudiation of the claim by the Opposite Party is a deficiency in service. The question in consideration is that whether the Complainant made his inception to the policy knowing that he has the ailment of diabeties mellitus. The Complainant had undergone treatment for swelling in the leg and acute diabeties. The claim form submitted to the insurance company is produced by the Opposite Party and it is marked as Ext.B4. B1 is the claim form which the party has to answer the question-naire accordingly the Ext.B1 is filled up and forwarded to the Opposite Party for the claim amount. The clause 7 of claim form is answered in such a way that the disease started from 10.9.2002 onwards and more over the discharge summary of the referred hospital the treatment summary explains that it is a known case of diabeties. The Complainant contested that the claim form was filled up by the 3rd person and the starting of the disease as written in the claim form is a mistake. The claim of the Complainant that the commencement of the disease from10.9.2002 is a casual mistake and it cannot be considered as such. The Complainant has no case as that he does not know reading and writing and more over the discharge summary treatments shows that the Complainant is a known diabetic patient. The treatments availed by the Complainant was for diabeties and the policy covers risk as per the term in the MOU in between the Opposite Party and Malabar Co-operative Milk Producers Unit. Apart from the claim form on verification of the documents we are in the opinion that the inception of the Complainant to the policy was suppressing the pre-existing disease. The repudiation of the claim by the Opposite party cannot be interfered. The point No.1 is found accordingly and the point No.2 does not arise for a detail discussion. In the result, the complaint is dismissed. No order as to cost.
Pronounced in open Forum on this the day of 29th June 2009.
PRESIDENT: Sd/-
MEMBER- I: Sd/-
MEMBER-II: Sd/-
A P P E N D I X
Witnesses for the Complainant:
PW1. Bhaskaran Complainant.
Witnesses for the Opposite Party:
OPW1. Rajesh Kumar. Administrative Officer, United India Insurance Company.
Exhibits for the Complainant:
A1. Copy of Claim Repudiation Letter. dt:28.11.2008. Exhibits for the Opposite Party:
B1. Claim Form. B2. Discharge Summary. B3. Copy of Policy Schedule. B4. Medical Report to be accompanied by usual claim from under hospitalization/ Domiciliary Hospitalization Benefit Policy.
B5. Copy of Claim Repudiation Letter. dt: 28.11.2008.
......................K GHEEVARGHESE
......................P Raveendran
......................SAJI MATHEW | | 
