(1.) OPPOSITE party is the appellant.
(2.) THE complainant had taken mediclaim insurance policy, from the opposite party, not only for himself, but also for the family members, from the year 2001, commencing from 27.6.2001, and the same was renewed, even for the period 2003 -2004.
(3.) IN the month of January 2003, the complainant's wife Kalaiselvi, had excessive bleedings and severe abdomen pain, for which she had taken treatment, in First Med Hospital at Chennai, where the disease was diagnosed as Adenomysis, for which laparoscopic assisted vaginal and hysterectomy, was done on 18.1.2003, for which she was hospitalized from 24.1.2003.The complainant had spent a total sum of Rs. 27,666.95, out which a sum of Rs.12,463.75 was reimbursed, since the complainant is working in a bank.Based upon the policy, though the complainant had not claimed any amount from the year 2001, for this treatment, claim was lodged for the balance, which was repudiated unjustifiably by the opposite party, as if it was a pre -existing one, or the complainant had suppressed the material facts, thereby causing not only mental agony, but also monetary loss, for which they should be directed to pay a sum of Rs. 1 lakh, in addition to the expenses incurred, viz. Rs.15,203.20. Hence the complaint.
The opposite party, while conceding the policy, taken by the complainant, would submit that there was no deficiency on their part, and in this view, the case itself is not maintainable.As per the discharge summary dated 25.1.2003, issued by First Med Hospital, the complainant's wife was suffering from disinenorrehea for one and half year, dysmenorrheal for one and half years, menfrrhogia for one and half year, history of passing clots, bleeding lasts for seven days for one and half years prior to admission in the hospital, which should be construed as if she was suffering from this illness, effective from 1.7.2001 Considering the close proximity of the commencement of the disease and the treatment taken, repudiation was taken, disclaiming liability, which cannot be treated or construed as deficiency, thereby praying for the dismissal of the complaint, denying further averments also.;