THE KARNATAKA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION, BANGALORE. (ADDL. BENCH)
DATED THIS THE 12th DAY OF JUNE, 2024
APPEAL NO.1944/2017
PRESENT
SRI RAVI SHANKAR, JUDICIAL MEMBER
SMT. SUNITA C.BAGEWADI, MEMBER
The Branch Manager,
National Insurance Company Ltd.,
D.O.I., 30, 2nd Floor, Bharathi Building ...Appellant/s
P.M.Rao Road, Mangaluru-575 001,
Now Reptd by the Regional Manager,
National Insurance Co. Ltd.,
No.144, Subharam Complex,
M.G.Road, Bengaluru-560 001
(By Sri.A.N.Krishna Swamy, Advocate)
-Versus-
Mr.Wilfred L.B.Sequeira (since dead)
S/o late Edwin Sequeira,
Aged about 65 years, ...Respondent/s
R/at Divya Deepa Residency
“KENWIL” LG02, Opp. ESI office,
Shivabagh, Mangaluru-5750 002
1a) Mrs.Vanita Sequira,
2b) Mrs.Vaneesa Saldana,
No.1a) Wife and No.1b) Daughter of
Late Mr.Wilfred L.B.Sequiera,
R/at Divya Deepa Residency,
Shivabhag Mangaluru
(Smt.Kavitha Saldanha, Advocate)
O R D E R
BY SRI RAVI SHANKAR, JUDICIAL MEMBER
The Appellant/Opposite Party No.1 in complaint No.418/2014 preferred this Appeal against the order passed by the Dakshina Kannada District Consumer Commission, Additional Bench, Mangaluru which directed this appellant to pay an amount of Rs.2,38,207.90 with interest @8% per annum and Rs.6,000/- litigation expenses and submits that the complainant had obtained a Mediclaim Insurance Policy towards his family and accordingly he was admitted to hospital for stomach pain and later it was diagnosed as heart and kidney diseases. He was taken treatment as an inpatient and spent nearly Rs.2,38,207.90. The claim made by the complainant was rejected for the reason of suppression of pre-existing diseases. Aggrieved by the same, the complainant approached the District Commission and sought for payment of the above said amount.
2. The District Commission after trial allowed the complaint and directed this appellant to pay the above said amount. In fact this appellant is not liable to pay any amount as claimed by the complainant and ordered by the District Commission. Since, the policy commenced in the year, 2013 and during the said policy, he was admitted to Vinayaka Hospital on 5-10-2013 for stomach pain and there he was diagnosed as heart and kidney diseases. Subsequently the policy was renewed from 14-2-2014 and the complainant got himself admitted on four occasions during subsistence of second policy and made a claim. This appellant repudiated the claim basing on the Section 4 (1) of the policy conditions which excluded pre-existing ailments for the first four years from the commencement of the policy. But the District Commission not considered the said clause and allowed the complaint. The order passed by the District Commission is not in accordance with law, hence prays to set aside the order passed by the District Commission and dismissed the complaint, in the interest of justice and equity.
3. Heard from both sides.
4. On perusal of the certified copy of the order and memorandum of appeal, it is not in dispute that the policy which was obtained by the complainant from this appellant/Opposite Party and this appellant/Opposite Party renewed the policy periodically without any break. It is also not in dispute that, the earlier the complainant had claimed for reimbursement for certain ailments. Such being the case, when he claimed for subsequent medical expenses, the claim was repudiated for the reason that he had not disclosed the pre-existing diseases such as Hypertension, Diabetes and Chronic Kidney diseases at procuring beginning of the policy and repudiated the claim. The repudiation made by this appellant is not justifiable. Once the policy was renewed periodically and continuously for more than four years automatically all ailments covered under the policy, the question of preexisting diseases does not arises. Here we noticed the complainant had obtained the policy in the year, 2013 and continuously renewed the policy. During the policy in force he had taken treatment for Heart and Kidney diseases. Merely non-disclosure of hypertension and diabetes not amounts violation of any terms and conditions of the policy.
5. The District Commission has rightly appreciated the facts and circumstances of the case and allowed the complaint. We do not find any irregularity in the order passed by the District Commission. At the same no valid grounds urged before this Commission to set aside the order passed by the District Commission. As such the appeal is dismissed and accordingly, we proceed to pass the following:-
O R D E R
The appeal is dismissed. No order as to cost.
The impugned order dated 16.08.2017 passed by the Dakshina Kannada District Consumer Disputes Redressal Commission, Additional Bench, Mangaluru in CC.No.418/2014 is confirmed.
The amount in deposit shall be transmitted to the concerned District Consumer Commission to pay the same to the complainant.
Send a copy of this order to both parties as well as Concerned District Commission.
Member Judicial Member
