Karnataka

StateCommission

A/1203/2017

M/s Religare Health Insurance Co Ltd. - Complainant(s)

Versus

Mrs. V.V.Vinni - Opp.Party(s)

27 Feb 2024

ORDER

Date of Filing :23.05.2017

Date of Disposal :27.02.2024

 

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

 

DATED:27.02.2024

 

PRESENT

 

HON’BLE Mr JUSTICE HULUVADI G RAMESH : PRESIDENT

 

Mr K BSANGANNANAVAR: JUDICIAL MEMBER

 

Mrs DIVYASHREE M:LADY MEMBER

 

 

APPEAL No.1203/2017

 

1. M/s Religare Health Insurance Co Ltd.,
    Gys Global,

    Plot No.A3,A4, A5,

    Sector 125, Noida, U

    Uttar Pradesh-201301

 

2. M/s Religare Health Insurance Co Ltd.
    Site No.8, 80 ft. Road,

    ST Bed Area, 2nd Floor,

    Koramangala,

    Near Manoraja Hotel,

    Bengaluru.

 

    Now Rep. by its Corporate Manager-Legal,

    M/s Religare Health Insurance

    Company India Ltd.,

    Office: 3^rd Floor, Vipul Tech Square

    Sector 43, Golf Course Road,

    Gurgaon – 122009                                                        Appellants

    (By Mr H N Keshava Prahanth, Advocate)

 

-Versus-

 

Mrs V V Vinni
W/o Mr VSrinivas Parthasarathy Reddy

Aged about 34 years,

R/at No.PH-1,

Kalpana's Paradise,

9^th Cross, Kodihalli,

HAL II Stage,

Bengaluru-560008

(By Mr P B Ajit, Advocate)                                                 Respondent  

 

 

                                               

:ORDER:

 

Mr JUSTICE HULUVADI G RAMESH : PRESIDENT

 

1.       This Appeal is filed under Section 15 of Consumer Protection Act 1986 by the OPs, aggrieved by the Order dated 14.02.2017 passed in Consumer Complaint No.1416/2014 on the file of I Additional District Consumer Disputes Redressal Forum, Bengaluru(hereinafter referred to as the District Forum).

2.       Heard the arguments of the learned Counsels on record, perused the Impugned Order, grounds of Appeal and secured records from the District Forum.

3.       The District Forum on enquiring into the matter, allowed the Complaint in part and OPs are jointly and severally held liable to pay a sum of Rs.5,00,000/- towards coverage of Insurance Policy, within 30 days from the date of receipt of the Order, failing which, OPs are directed to pay interest @ 9% p.a on the said amount from the Date of receipt of the Order, till realisation with costs of Rs.2,000/- to the Complainant within 30 days from the date of the Order.  

4.       Aggrieved by this Order, OPs are in Appeal inter-alia contending amongst other grounds, that the District Forum ought to have seen  and give more weightage to the document  produced by the Complainant which is marked as Annexure-C, which clearly demonstrates that it is a case of hypertrophic Cardiomyopathy with a family history of sudden cardiac arrest. Without understanding the contents of the said document properly, has erroneously held that the Company is liable to pay the compensation. Thus, the Impugned Order is bad in law and liable to be set aside by allowing the Appeal.

5.       The observation of the District Forum in its Impugned Order that husband of the complainant Mr VSrinivas Parthasarathy Reddy has obtained the Health Insurance Policy in the month of November 2012; same was renewed in the month of November 2013 and he underwent treatment for Hypertrophic Cadiomyopathy and incurred medical expenditure of Rs.5,30,000/-.   OP on receipt of the Claim, did not honour the same on the ground that Hypertrophic Cardiomyopathy along with family history is autosomal dominant which is genetic in nature and congenital diseases are not covered under the policy.   Complainant has deposed that Dr AMKarthigesa of M/s Apollo Hospital issued a Certificate Dated 17.05.2014 confirming that Hypertrophic Cardimyopathy is neither congenital nor birth defect. Further complainant averred that Dr KMeenakshi who has earlier given the contrary report also certified that Hypertrophic Cardiomyopathy neither a congenital heart disease nor birth defect. Per contra, OPs also contended that Hypertrophic Cardiomyopathy is a genetic one and it is exclude, as per the Insurance Terms and Conditions.   The burden lies on the OPs to rebut the evidence of the Complainant, OPs though filed the Annexure-E, the expert opinion of Dr. C.H.Asrani before the District Forum but, did not examine the expert i.e., Dr C H Asrani   and in the absence of evidence of an Expert, merely filing of the opinion styled as to ‘whomsoever it may concern’ cannot be helpful to substantiate the contention of the OP.  The object of Insurance is to cover the risk arising out of un-known disease.

6.       Admittedly, Mr.Srinivas Parthasarathy Reddy, deceased husband of the complainant has obtained the Health Insurance Policy in the month of November 2012 and same was renewed in the month of November 2013.  During the subsistence of the Policy, he underwent treatment for Hypertrophic Cardiomyopathy and incurred medical expenditure of Rs.5,30,000/-.  Further on perusal of document No.5& 6 produced by the complainant before the District Forum, it is seen that Document No.5 is the Certificate issued by Dr A M Karthigesa of M/s Apollo Hospital Dated 17.05.2014, which discloses that Hypertrophic Cardimyopathy is neither congenital nor birth defect.  Further, the Document No.7 - Certificate issued by Dr K Meenakshi also discloses that Hypertrophic Cardiomyopathy is neither a congenital heart disease nor birth defect.  Further, on perusal of the Medical Bills produced before the District Forum by the Complainant, it is seen that a sum of Rs.5,81,660/- was spent towards medical expenditure.  Further on perusal of the Document No.1, produced by the Complainant, before the District Forum is the Policy document, wherein, it reflects that the Policy Sum Assured is Rs.5 lakhs. Thus, the act of OP in not reimbursing the Hospital charges to the Complainant, amounts to deficiency in service and Impugned Order directing the OPs to Rs.5,00,000/- towards coverage of Insurance Policy with interest @ 9% p.a and costs of Rs.2,000/- to the Complainant, is just and proper and same does not call for any interference.  Accordingly, Appeal stands Dismissed.

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

 

8.       Return the LCR forthwith to the District Commission.

                

9.       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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