By Smt Padmini Sudheesh, President <br /> <br /> Petitioner’s case in brief is as follows:<br /> <br /> The 2nd respondent has issued a Janarogya Bhima Policy No.3911589 in the name of 1st respondent in which complainant is a policy holder of one year from 1/12/01. As per the directions of the respondents the complainant has undergone a medical check-up and was found fit. Subsequently on 12/6/02, within the policy period the wife of the petitioner was admitted in a Hospital named Chazhikad Hospital Pvt. Ltd. at Thodupuzha and was discharged on 18/6/02. Later the petitioner claimed the policy benefits, but was repudiated by stating pre-existing diseases are excluded from the purview of the policy. There was no disease at the time of taking the policy. Lawyer notice sent to 1st respondent, reply was received. In the reply 2nd respondent has stated that they have no liability. Hence this complaint.<br /> <br /> 2.1st respondent has filed Counter to the effect that there is no privity of contract between the complainant and the 1st respondent and has never undertaken to indemnify the complaint. <br /> <br /> 3.The Counter of 2nd respondent in brief is as follows :- As per the policy the Company will pay to the insured person the amount of such expenses as are reasonably and not exceeding in any one period of insurance the sum assured of Rs.5,000/- towards medical expenses. As per the policy conditions and exclusions, the diseases which have been in existence at the time of proposing for this insurance are excluded. The complainant has undergone treatment for the disease “Papillay Neoplasmi Thyroid” and which is excluded as per clause 4.3 of the policy. Hence dismiss.<br /> <br /> 4.The points for consideration are<br /> 1)Whether the petitioner is entitled for the policy benefits as prayed?<br /> 2)Reliefs and costs ? <br /> <br /> 5.The evidence consists of exhibits P1 to P11 and R1 to R7.<br /> <br /> 6.Point No.1 The 2nd respondent has rejected the petitioner’s claim since the ailment was pre-existing and was excluded during the first years of operation of insurance cover. Hence not covered as per the policy issued. In this case the petitioner’s wife is the person suffered from the disease. As per the records it can be seen that the date of admission is 12/6/02 and it was within the policy period. Ext. P4 shows that the probable part duration of illness as reported by the patient is two months. It is true that no document from the Medical College Hospital is produced. But no patient will lie to a doctor only to achieve policy benefits. Moreover, before joining in the policy medical check up was done and it was found fit. So repudiation of the claim on the basis of pre-existing is not acceptable. Even if the expenses are more than Rs.5,000/-,the petitioner is only entitled to get Rs.5000/- as per the policy terms.<br /> <br /> 7.In the result this complaint is allowed and the 2nd respondent is directed to provide Rs.5,000/- to the petitioner with 12% interest per annum from 12/6/02 and 6% interest from today till realization. Respondent is also directed to pay Rs.500/- towards casts. Comply the order within one month.<br /> <br /> Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open forum this the 7th day of July 2008.<br />