The 1st complainant was a member of Elite Health Care Scheme conducted by the respondents 1 and 3. In order to join the scheme the first complainant paid Rs.3,000/- on 19/1/2000 and became a subscriber of the scheme. At the time of joining it was told that if Rs.3,000/- paid the first complainant will be eligible for medical benefits of Rs.15,000/- per year and also assured that free treatment facility will be available for all the diseases. The diseases which are excluded from the purview of the scheme are also intimated.

Later the first complainant was treated in the 1st respondent’s Hospital for chest pain and the treatment expenses were met by the first respondent hospital. Subsequently on 31/1/02 he was admitted in the first respondents hospital due to chest pain and discharged on 7/2/02. The doctor who had treated him stated that he was suffered for Coronary Artery disease. And also on 18/3/02 the first complainant was received a letter from 1st respondent stating that since 3rd respondent failed to pay the entire expenses he had to pay Rs.6,560/-. He also received a letter on 4/4/02 stating that he is not eligible to get medical benefits from 1st respondent. It was also stated that he had to pay Rs.18,254/- in total. This is an unfair trade practice and shows deficiency in service. Hence this complaint.

2. During the pendency of the case the first complainant was died and legal heirs were impleaded as petitioners 2 to 6.

3. The averments in the counter 1st and 2nd respondents are:
It is true that the first complainant was a subscriber of the Elite Health Care Scheme and paid Rs.3,000/- and was entitled for medical benefits for Rs.15,000/-. From 21/3/2000 to 14/6/2001 the first complainant was treated many times and claims were co approved by the 3rd respondent. After that 3rd respondent did not co approve the claims and first complainant had to pay Rs.18,254/-. These respondents enquired with the 3rd respondent about non payment of the claims. They replied that the complainant was suffered from the disease before the policy and also suffered from age related changes diseases. So they were unable to honour claims of first complainant. The 3rd respondent may be directed to allow claims of the complainant and dismiss the case against these respondents.

The Counter of 3rd Respondemt is as follows:

4. This respondent denies that the complainant is a member of the Elite Health Care Scheme and this respondent is not aware of the scheme and denies the contract between the first complainant and the 1st and 2nd respondents. As per the Health Care Scheme the complainant was treated several times and he got benefits of the scheme. As per the MRI Scan report it was revealed that the first complainant was suffered from age related degenerative changes. As per our policy preexisting diseases are excluded from the purview of the policy. So this respondent is not liable to give any amount. Hence dismiss.

5. The points for consideration are :
1) Is there any deficiency in service ?
2) If so reliefs and costs ?

6. The evidence consists of Exhibits P1 to P5 and Exhibits R1 to R12 on the part of respondents 1 and 2 and R13 to R19 on the part of 3rd respondent.

7. Points: The complaint is filed to get insurance policy benefits. The case of complainant is that the first complainant who was the husband of second complainant and father of other complainants was a member of Elite Health Care Scheme conducted by the respondents 1 and 3. The first complainant paid Rs.3,000/- on 19/1/2000 and became a subscriber. Later the first complainant was treated in the 1st respondent’s hospital for chest pain and the treatment expenses were met by the first respondent hospital. According to them for the treatment done from 31/1/02 to 7/2/02 the expenses for the treatment done were not fully paid by the 3rdt respondent company.

So letters were received from 1st respondent demanding to pay Rs.18,254/-. So this complaint is filed by challenging the acts of respondents. In the counter 1st and 2nd respondents stated that being a subscriber of the policy the first complainant was entitled to get treatment expenses from 3rd respondent. They also stated that the treatment expenses during 21/3/2000 to 14/6/2001 were fully co approved by the 3rd respondent. After that the 3rd respondent refused to honour the entire bill amount. So these respondents enquire the matter with the 3rd respondent and the 3rd respondent replied that the first complainant was suffered from the disease before the policy. It was also stated in the reply that age related changes diseases are excluded from on the purview of the policy. In the counter they also stated that the policy was renewed on 19/1/01 also. So according to them the complainant is entitled to get the policy benefit.

8. The 3rd respondent filed counter stating that as per the policy pre exist diseases are excluded from the purview of the policy. So the complainants are not entitled for any amount.

9. Exhibit P1 is the notice issued by 1st and 2nd respondents in connection with the Elite Health Care Scheme. It shows that the subscribers who are paying Rs.3,000/- are entitled to get treatment expenses of Rs.15,000/- per year. It also shows that the duration of each unit is 5 years. As per Exhibit P2 receipt the first complainant joined the scheme by paying Rs.3,000/- on 19/1/2000. So the deceased was entitled for treatment expenses up to Rs.15,000/- per year. It is admitted by 1st and 2nd respondents that the first complainant got treatment expenses for Rs.15,461/-. The treatment expenses during 18/7/01 to 7/2/02 were not fully paid by the 3rd respondent. According to 1st and 2nd respondents Rs.18,254/- is to be availed from the 3rd respondent. 1st and 2nd respondents stated that they enquired the matter with the 3rd respondent and the 3rd respondent replied the matter to 1st and 2nd respondents. Exhibit R9 is the reply sent by the insurance company.

It shows that the claim of deceased Ouseph was refused by the company due to reasons stated as pre existence of diseases and age related changes diseases. According to the 3rd respondent the first complainant was suffered from the disease before inception of the policy. They also produced the policy conditions and is marked as Exhibits R18. Clause 4-1 shows that all diseases or injuries which are pre existing when the cover incepts for the first time are excluded from the policy. As per Exhibit P2 on 19/1/2000 the first complainant joined the policy. As per Exhibit P1 notice duration was for 5 years without renewal. The dishonoured treatment expenses were well in the coverage of policy and the complainants are entitled to get it. Exhibit R6 is the copy of claim form reveals the history of illness as one day. The date of first consultation with the doctor stated as 31/1/02. So the clause of pre existence of diseases will not attract. Exhibit R3 is the copy of his another claim form shows the history of illness as one week. The date of first consultation with the doctor stated as 23/7/2001. There is no evidence to show that the first complainant was suffered diseases before the inception of the course. There is also no evidence about the knowledge of diseases prior to the policy. The allegation of 3rd respondent is seen baseless. Exhibit P1 notice also shows that there is no medical check up necessary before joining the policy. So the 3rd respondent can not repudiate the claim by stating preexistence of disease and age related disease. The maximum age stated is 75. At the time of joining deceased Ouseph was 62 years of age. So the 3rd respondent can not repudiate the claim on this ground also. The 3rd respondent is liable to pay the treatment expenses of Rs.18, 254/- to respondents 1 and 2.

10. In the complaint they have sought for compensation and costs from first respondent. Exhibits P4 and P5 are the copies of letters sent by first respondent to the deceased Ouseph. In both the letters it is stated that balance amount to be paid by the first complainant. According to the first respondent since the amount was not paid by the 3rd respondent it is the duty of patient to pay treatment expenses of him. From the records it can be seen that the first respondent hospital had done their duty to get insurance benefits from the 3rd respondent. So there is no deficiency in service or unfair trade practice on the part of hospital and doctor. The 3rd respondent is only liable to pay the amount sought by the 1st respondent in Exhibits R4 and R5.

11. In the result the complaint is partly allowed and the 3rd respondent is directed to pay Rs.18,254/- (Rupees Eighteen thousand two hundred and fifty four only) to the 1st respondent and the complainants are exonerated from the payment to 1st respondent. The 3rd respondent is further directed to pay Rs.2,500/- (Rupees Two thousand and five hundred only) as compensation with Rs.500/- (Rupees Five hundred only) as costs within one month.