By Smt. Padmini Sudheesh, President: Petitioners case is as follows: 1. The petitioner and his wife are policyholders of Medi Guard Policy of the respondent Company. They joined in the policy on 21.6.04. The period of the policy was one year and before the expiration of that period, the petitioner and his wife renewed the policy for another one year. As per the renewal, the policy is extended from 21.6.05 to 20.6.06 and a policy certificate No.100600/48/05/00715 is issued. At the time of renewal of the policy the petitioner had no diseases. But on July 2005 onwards he was suffering from piles. On 25.12.05 he felt severe pain and admitted in Karthiayani Nursing Home and Doctor suggested surgery of piles. And on 28.12.05 he had undergone surgery of piles and discharged on 30.12.05. He says that he spent an amount of Rs.10,000/- for his treatment. He approached several times the respondent company for reimbursement of the amount, but had not entertained the claim. Lawyer notice sent. No reply, no remedy. Hence this complaint. 2. The respondents counter is as follows: The averment in the complaint that the petitioner was not having any disease at the time of renewal of policy is not correct. The complainant was suffering from piles, was known to the complainant in July 2005 only is not correct. Rs.10,000/- is spent for treatment is also not correct. The respondent admits the policy in the name of the complainant for the period from 21.6.05 to 20.6.06 is subject to terms, conditions and exclusions of the policy. The complainant has suppressed the material facts at the time of taking policy and there is fraud from the part of the petitioner. The respondent appointed an investigator and the Investigation report reveals that he had taken treatment for piles during May 2005 near an Ayurvedic Physician. He also consulted Dr. Paul Kallookkaran at Poly Clinic, Thrissur and the doctor advised for surgery and the surgery was fixed for Christmas holidays. And on 25.12.05 he was admitted at Karthiayani Nursing Home and on 25.12.05 surgery is conducted. The petitioner is suffering from the disease for the last 45 years. Treatment of piles is excluded from the policy. So company is not liable. The claim of the petitioner repudiated as pre-existing. Hence dismiss the complaint. 3. The points arise for consideration are: - (1) Whether the petitioner is entitled for the insurance claim? (2) Reliefs and costs. 4. The evidence consists of Exts.P1 to P6 and R1 to R10. 5. Point No.1: Petitioners case is that as per the policy, he is entitled for the treatment expenses. But the claim has repudiated by the company stating that all pre-existing diseases are excluded from the scope of policy benefits. In this case the petitioner joined in the policy on 21.6.04. The policy is renewed for another one year also. According to the petitioner he had the experience of piles only on July 2005 onwards. At the time of joining he has no disease like piles. As per Ext. R9 the disease of piles is excluded from the purview of the policy. In Ext. R10 also this is affirmed. In Ext. R10 the petitioner stated that he has not suffering from the disease mentioned in it. As per this statement policy is issued. At the time of joining the respondent company requires no medical check up. After joining the policy the respondent company is putting forward untenable grounds to reject the claim. Before issuing policy certificate, the company had to assure that the applicants are not suffering from the diseases, which are excluded from the policy coverage. After receiving the premium and making assurances, it is not fair to repudiate the claim on flimsy grounds. The insurance is being taken for financial assistance and if it is rejected by the company on unreasonable grounds, the very purpose will be futile. So the petitioner is entitled for the benefits. 6. Point No.2: Ext. P4 series is the documents revealing the expenses incurred. As per that document, he is entitled for Rs.8128-01. No other expenses are proved by document. So he is entitled for that amount. 7. In the result the petition is allowed and the respondent is directed to pay Rs.8128/- (Rupees eight thousand one hundred and twenty eight only) to the petitioner with interest at the rate of 12% per annum from 25.12.05 till realization and costs of Rs.500/- (Rupees five hundred only). Time for payment one month. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 16th day of May 2008.
