Karnataka

StateCommission

A/195/2018

Head of Claim Cholamandalam MS General Insurance Company Ltd., - Complainant(s)

Versus

K.Mohammad Khalli - Opp.Party(s)

S.Krishna Kishore

29 Feb 2024

ORDER

     Date of Filing: 07.02.2018

    Date of Disposal:29.02.2024

 

BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU (PRINCIPAL BENCH)

 

DATED:29.02.2024

 

PRESENT

 

HON’BLE Mr JUSTICE HULUVADI G RAMESH : PRESIDENT

 

Mr K BSANGANNANAVAR: JUDICIAL MEMBER

 

Mrs DIVYASHREE M:LADY MEMBER

 

 

APPEAL No.195/2018

 

 

Head of Claim

Cholamandalam MS General Insurance

Company Ltd., No.4, 9^th Floor, (Level-6),

Golden Heights, 59^th C Cross,

Industrial Suburb, Rajajinagar

4^th M Block, Bangalore-560010

Rep. by its Deputy Manager, Mr Sunil Ramesh
(By Mr S.Krishna Kishore, Advocate)                                       Appellant

 

-Versus-

1. Mr K.Mohammad Khalli,
    Aged about 54 years,

    S/o K.Abdul Rahiman,

    R/at No.82-1, ‘Ashrafi’ Kallotte,

    Karkala Kasaba Village,

    Karkala Tq., Udupi Dist.
    (By Mr Yashavanth S, Advocate)   

 

2. The Chief Medical Officer
    Kasturba Hospital,

    Manipal, Udupi Dist.

 

3. Central Bank of India
    Karkala Branch

    Gasper Luise Building,

    Mangalore Road, Karkala,

    Udupi Tq. & District                                                        Respondents

    (By Mr H.Nagesh, Advocate)

 

:ORDER:

 

Mr JUSTICE HULUVADI G RAMESH : PRESIDENT

 

1.       This Appeal is filed under Section 15 of Consumer Protection Act 1986 by the OP2, aggrieved by the Order dated 29.11.2017 passed in Consumer Complaint No.32/2016 on the file of District Consumer Disputes Redressal Forum, Udupi (hereinafter referred to as the District Forum).

2.       Heard the arguments of the learned Counsels for Appellant and Respondent Nos.1 & 3. Inspite of due service of Notice for appearance from this Commission on Respondent No.2, neither he appeared in person nor any one represented him and hence, his arguments is taken as heard.

3.       Perused the Impugned Order, grounds of Appeal and records secured from the District Forum.

4.       The District Forum after enquiring into the matter, allowed the Complaint and directed OPs 1 to 3 to pay Rs.1,48,709/- with interest @ 9% p.a from 08.02.2016 till payment, Rs.10,000/- as compensation and Rs.5,000/- as legal expenses, within 30 days from the Date of the Order.   The District Forum Dismissed the Complaint as against OPs 4 and 5. 

5.       Aggrieved by this order, OP2 is in appeal contending that District Forum erred in entertaining the claim of the Respondent 1/Complainant, though the Discharge Summary issued by the Hospital, where the Respondent No.1 took treatment has clearly mentioned that the Respondent No.1 is a known case of Diabetes and Hypertension.  Impugned Order is contrary to the medical records produced by Respondent No.1, Terms & Conditions and exclusions of the Medi-claim Policy and thus seeks to set aside the Impugned Order by allowing the Appeal.

6.       The Complainant averred that he had obtained the Family Health Chola Swasth Parivar-pearl Policy bearing No.2856/00164534/000/00 from OP2 for on 18.11.2014, covering the risk of himself, his wife and child.   On 09.09.2015, the Complainant got admitted to the Kasturaba Hospital/OP4 for the ailment of chest pain, angiography & angioplasty were carried out and he had incurred Medical expenses to an extent of Rs.1,48,709/- for his in-patient treatment and submitted the Claim to the OP2 for reimbursement of Rs.1,48,709/-, which was repudiated on the ground that ailment is because of pre-existing disease.

7.       The stand taken by the OPs that the Angiogram Report issued by the Kasturaba Hospital clearly mentioned that risk factors for coronary artery disease is due to Diabetes & Hypertension and inspite of several reminders, Complainant not produced the treatment papers for processing the Claim.

8.       The District Forum in Para 14 of its Impugned Order recorded its findings that ‘DM and HTN is not a serious disease to be considered as a cause for repudiation of the Medi-claim Policy claim as non-disclosure of pre disease. There is no solid & acceptable proof to show that the Complainant was taking treatment for DM and HTN before taking the Policy or he has encountered any of the complications relating to DM and HTN’.

9.       Admittedly, complainant obtained the Family Health Chola Swasth Parivar-pearl Policy bearing No.2856/00164534/000/00 from OP2 on 18.11.2014, covering the risk of himself, his wife and child.   The Complainant got himself admitted to the Kasturaba Hospital on 09.09.2015 for the ailment of chest pain, took treatment for Angiography and Angioplasty and incurred  expenses to an extent of Rs.1,48,709/- for the in-patient medical treatment.  On perusal of Ex-P1 the Policy document and its schedule, it is seen that Sl. No.118 - Kasturaba Hospital, Manipal is covered under the Policy Schedule. Further on perusal of Ex-R1, the policy Terms & Conditions  under head A : Definition in Sl. No.34 it is mentioned that – ‘Pre-existing condition’ – Any condition, ailment or injury or related conditions for which you had signs or symptoms and/or were diagnosed and/or received medical advice/treatment, within 48 months prior to incepting of your first policy with us’.  Further under Head B: Coverage section I- 1) Hospitalisation Expenses in clause d) it is mentioned that – ‘the claim amount payable per person towards the treatment of under mentioned disease/surgery/ procedure during the Policy period subject to the disease and limit for claim in every Policy year’ it is seen that under Sl. No.14 & 15 it is mentioned that for coronary Angiography Rs.20,000/- and for Cornorary Angioplasty  Rs.1,00,000/-. Thus, Policy Terms & Conditions clearly discloses the confirmation for reimbursement of medical expenses towards Coronary Angiography and Coronary Angioplasty incurred by the Insured personnel, it is not exclusions of medi-claim policy and it cannot be said that the claim is for non-disclosure of pre-disease and unfortunately both the above are treatment of sudden onset of dis-orders. The contention of the OPs that the Complainant taking treatment for DM and HTN before taking the policy or he suffered DM and HTN before taking the policy as per Discharge Summary holds no water in the present case. We are of the considered opinion that un-acceptable conservative approach of the Insurance Companies, who somehow want to invent reasons for repudiation of Medical reimbursement claims, which action of theirs, defeats the very purpose of introduction of Insurance Scheme and service should be the motto, when Premiums are collected with all earnestness, even without bothering to check the basic compliances and they awake only when Claims are received. Under the circumstances, the Impugned Order passed by the District Forum is hereby confirmed and accordingly, Appeal is dismissed with no order as to costs.

10.     The Statutory Deposit in this Appeal is directed to be transferred to the District Commission for further needful.

 

11.     Return the LCR forthwith to the District Commission.

                

12.     Send a copy of this Order to the District Commission, as well as to the parties concerned, immediately.

 

 

 

Lady Member                  Judicial Member                         President

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