O R D E R

By  Sri.P.K,.Sasi, President

        The case of the complainant is that the 2^nd complainant has taken an insurance policy by named PNB-Oriental Royal Mediclaim policy from the 2^nd opposite party through the 1^st opposite party. The complainants and their children are covered under the policy and it was valid from 29/06/15 to 28/06/16. During the policy period the 1^st complainant undergone treatments at Daya Hospital from 18/08/15 to 19/08/15 and he also treated at Amala Hospital from 4/9/15 to 7/9/15. A claim was submitted before the 2^nd opposite party for the expenses incurred whereas, the opposite party denied the claim stating that he has undergone treatments for a pre-existing disease. The act of the opposite party is illegal and amounts to deficiency in service on their part. Hence a lawyer notice was issued on 29/05/16. Eventhen, no relief received hence, this complaint is filed for getting relief.

        2) On receiving complaint notice was issued to both the opposite parties whereas, the 1^st opposite party even after accepting the notice neither appeared before the Forum nor filed any version hence, set ex-parte. The 2^nd opposite party however filed Wakkalath no version filed despite several chances given hence, 2^nd opposite party is also set ex-parte and posted for complainant’s evidence. From the side of complainant the 1^st complainant appeared before the Forum and submitted proof affidavit in which he has affirmed and explained all the averments stated in the complaint in detail. He also produced 6 documents which are marked as Ext.P1 to P6. Ext. P1 is the policy schedule; Ext. P2 is the claim repudiation letter dtd. 28/12/15; Ext. P3 is another claim repudiation letter dtd.28/12/15; Ext. P4 is the copy of lawyer notice with postal receipt dtd.21/5/16; Ext. P5 series 2 Nos. A/D cards and Ext. P6 is the copy of inpatient final bill received from Amala Institute of Medical Science. Since there is no contra evidence available before us from both the opposite parties we are inclined to accept the proof affidavit filed by the complainant. We heard the complainant’s counsel in detail and perused the documents produced.

        3) Ext. P1 would go to show that the 2^nd complainant has taken a mediclaim policy through 1^st opposite party as an agent from the 2^nd opposite party. The sum insured of the policy was Rs.1,00,000/-. Ext. P2 & P3 claim repudiation letters would go to show that the opposite party has rejected the claim as per the policy condition exception clause 4.1 pre existing disease no treatment records are available before us. It is a clear case of the complainant that they have submitted a claim with all treatment records before the 2^nd opposite party that can be seen from the Ext. P2 & P3 rejection letters. Here the burden is upon the 2^nd opposite party to prove before the Forum that they have repudiated the claim with genuine reason of pre-existing disease. Nothing has been done by the opposite parties.

        4) Considering all these points we are inclined to allow this complaint and the 2^nd opposite party is directed to pay Rs.1,00,000/- to the complainant’s with 9% interest from the date of complaint within one month from receiving copy of this order. There is no separate order regarding compensation and cost. Failing which, the complainant is entitled to get 9% interest till realization.

        Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum this the     31^st day of January 2017.