ORDER

Sunil Kumar Garg, President - This appeal under Section 15 of the Consumer Protection Act, 1986 has been filed by the appellants Insurance Co. which were opposite party Nos. 1 and 2 before the District Forum against order dated 18.12.2008 passed by the District forum, Jaipur Camp, Jaipur in Complaint No. 396-08 by which the complaint of the complainant respondent was allowed in the manner that the appellants were directed to pay a sum of Rs. 5,299 + Rs. 50,476 total Rs. 55,775, the amount incurred by the complainant respondent in the treatment of his son within 45 days failing which the appellants would further pay interest @ 9% p.a. on the above amount from the date of passing of the order and further they were directed to pay a sum of Rs. 3,000 as costs of litigation and Rs. 5,000 as compensation for mental agony.

2. It arises in the following circumstances

That the complainant respondent had filed a complaint against the appellants before the District Forum, Jaipur on 16.6.2008 inter alia stating that the complainant respondent had taken a Mediclaim Policy for himself on 18.10.2002 for one year and thereafter he had got that policy renewed w.e.f. 17.10.2003 and under the renewed policy apart from the complainant respondent, his wife Smt. Jyoti, Divaspati (son) Shivani (daughter) and Vagmita (daughter) were who got insured and in other words they were also members of the mediclaim policy which was in force w.e.f. 17.10.2003. It was further stated in the complaint that thereafter the said policy was again renewed by the complainant respondent on 12.10.2004 for one year and in the renewed policy the members were the same. It was further stated in the complaint that his son Divaspati who is also one of the insured persons in the policy, had developed ear problem with pus discharge and pain in the month of July 2004 and for that he had consulted several doctors and on the basis of the diagnosis it was found that the pus discharge and pain were related to posterior right ear retraction pocket as a result of which patient had also developed hearing loss and apart from some problem in the ear his son was having problem of deviation in the nasal septum known as DNS ( Deviated Nasal Septum ). It was further stated in the complaint that thereafter his son Divaspati was got admitted in the SMS Hospital, Jaipur in the unit of Dr. S.P. Srivastava, ENT Surgeon on 19.10.2004 and was discharged on 20.10.2004 and the diagnosis which was made by the doctor was DNS and in the pre-operative note it was also mentioned that he was a patient of cold, cough and hearing loss since childhood and that is marked as Anx. R-l and operation of Septoplasty was done. It was further stated in the complaint that a claim for a sum of Rs. 5,299 was submitted by the complainant respondent for reimbursement being the expenses incurred in connection with the said hospitalization and operation but that claim was repudiated by Paramount Health Services Pvt. Ltd. On behalf of the appellants through letter dated 14.12.2004 (Anx. R-4 ) in the following manner

"We have received your documents for claim processing based on our review, we find that the claim does not fall under the perview of the policy for the following reasons

Patient was admitted with rec cold, cough with hearing loss since childhood. Therefore, case can be repudiated under pre-existing Clause 4.1 of the policy.

If we will not get any response within 15 days, the same shall be conveyed to the insured.

Hence we regret to convey that the claim is not payable."

It was further stated in the complaint that the said repudiation was wrong one as was evident from the certificate given by Dr. S.P. Srivastava (Anx. R-3) which is quoted here for reference

"This is to certify that Mr. Divaspati Singh who was under my care suffered from recurrent cold and cough since childhood. Seven months ago he had a problem of pus discharge from his right ear which caused partial hearing loss he underwent septoplasty on 20.10.