M. THANIKACHALAM J. - (1.) The complainant is the appellant.
(2.) The complainant/appellant, had taken hospitalization and domiciliary hospitalization benefit policy, from the 2nd opposite party, for the period covering 20.5.2005 to 19.5.2006, through the 1st opposite party, for the sum assured Rs.1,50,000/-. The complainant who was suffering from abdominal pain, admitted in Apollo Hospital, where he was treated for Acute Pancreatitis, for the period 2.7.2005 to 16.7.2005, for which he spent more than Rs. 2 lakhs. After discharge, the complainant based upon the policy, lodged a claim, which was negatived/repudiated, on the ground that the complainant had taken treatment for pre-existing disease, which is not covered under the policy, though fact being it is not a pre-existing disease. The non-settlement of the insurance claim by the opposite party, would amount to deficiency in service. Despite number of request, they failed to pay the amount, which should be construed as negligent act, followed by deficiency, for which the complainant is entitled to compensation also, including the medical expenses incurred, totaling a sum of s.2 lakhs. Hence this complaint.
(3.) The opposite party, admitting the mediclaim policy, as well as the treatment taken by the complainant in Apollo Hospital, resisted the case, interalia contending, that even before the date of inception of the policy, the complainant had this kind of problem, for which he had taken treatment, and subsequently also he suffered by the same type of abdominal pain, for which he had taken treatment, which should come within the meaning of pre-existing disease, and therefore the repudiation of the claim is justifiable, not warranting to label it as negligent act, or deficiency in service, praying for the dismissal of the complaint.;