M.THANIKACHALAM, J. - (1.) The 1st opposite party challenges the order of the District Forum dt.20.4.2010, wherein a direction has been given against opposite parties to pay a sum of Rs.3 lakh, towards mediclaim payable to the complainant, with compensation of Rs.25000/- plus Rs.5000/- as cost, based upon deficiency in service.
(2.) Particulars needed for the disposal of appeal: The complainant/ 1st respondent, had taken mediclaim insurance policy, with the 1st opposite party from 13.2.99, periodically renewing upto 31.1.2007, paying a premium, covering not only the complainant, but also his family members, and the cover was Rs.3 lakhs each. On the basis of the policy, cashless hospitalization facility was provided, and on that basis, on the advise of Dr.Suryanarayanan, the complainant had undergone replacement of both knee joints, by surgery, for which he had incurred a sum of Rs.3,20,198/-, which is to be claimed, on the basis of authorization obtained from the 2nd opposite party, which was denied, as if the ailment comes within the exclusion clause of the policy, thereby the opposite parties have committed deficiency in not settling the medical bill, based upon the policy. Thus alleging deficiency, proceeded by negligence, consumer complaint was filed, not only for the sum insured viz. Rs.3 lakhs, but also for a sum of Rs.2 lakhs, towards compensation for mental agony, with cost.
(3.) The 1st opposite party, conceding the mediclaim policy availed by the complainant, as a card member of Citi Bank, at the first instance, and the renewal of the policy upto 31.1.2007, opposed the claim, contending that even at the inception of the policy in the year 1999, the complainant was suffering from arthritis, which was revealed in the proposal, that under the policy, any treatment taken for the pre-existing disease is excluded, and therefore the autorisation denied by the2nd opposite party or non-settlement of the claim by the 1st opposite party, will not come within the meaning of deficiency in service, praying for the dismissal of the complaint.;