M.THANIKACHALAM J. - (1.) The opposite party in C.C.45/2005 on the file of the District Consumer Disputes Redressal Forum, Erode, is the appellant.
(2.) The complainant/respondent had taken mediclaim policy for the period 27.06.2001 to 26.06.2002 for a sum of Rs.50,000/- and another mediclaim policy which was valid upto 27.06.2003. Because of some illness, the complainant was admitted in Sri Ramakrishna Hospital on 13.05.2002 and discharged on 10.06.2002. The expenditure incurred was approximately Rs.50,000/-. Similarly, the complainant was taking treatment during the currency of the second mediclaim policy, being an inpatient between 5.10.2002 to 21.10.2002, for which, he had spent a sum of Rs.50,000/- in Sri Ramakrishna Hospital, Coimbatore. On the basis of the illness and for the amount spent towards medical expenditure, having valid policy, when the claimant sought the reimbursement of the amounts, the same were repudiated by the Insurance Company, on false and untenable grounds, for which, they should be construed as committed deficiency in service, for which, they are liable to pay a sum of Rs.1 lakh with interest thereon as well another sum of Rs.50,000/- for compensation towards mental agony, anxiety etc., Hence, the claim.
(3.) The complainant submitted proposal for mediclaim insurance policy, wherein, he has declared that he is not suffering from any ailment, sickness or injury. Accordingly, the policy was issued, for the period, commencing from 27.06.2001 to 26.06.2002, which was subsequently renewed with a break from 28.06.2002 to 27.06.2003. The complainant lodged the mediclaim with reference to the policy in question, on 11.07.2003 for multiple Myeloma and Chronic Loculated Empyeme Thoracis, for the period 5.10.2002 to 21.10.2002 and 13.05.2002 to 10.06.2002. As per the rules, within 7 days from the date of hospitalization, claim should have been and details should have been submitted within 30 days from the date of discharge from the hospital. Since the complainant failed to do so, he is not entitled to claim the amount, assured under mediclaim policies. The complainant had taken treatment for two diseases called Multiple Myeloma and Chronic Loculated Empyeme Thoracis should have been present even before taking the policy i.e. to say that the complainant must have been suffering from the said diseases even before 27.06.2001, which he has failed to disclose at the time of giving the proposal. Thus, the complainant has violated the terms and conditions of the mediclaim policy, and therefore the claim was repudiated, not only on that ground, but also on the ground of limitation. On the above lines, the claim was opposed.;