THE KARNATAKA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION, BANGALORE. (ADDL. BENCH)
DATED THIS THE 21st DAY OF APRIL 2022
PRESENT
SRI RAVI SHANKAR – JUDICIAL MEMBER
SMT. SUNITA C.BAGEWADI – MEMBER
APPEAL NO. 913/2014
Sri. Manjunath B.S.
S/o Sri.Shankaralingaiah
Age: 39 years, R/at 1358/A,
5th Main, 2nd Stage, ‘E” Block,
Rajajinagar, Bangalore-560 010.
….Appellant/s.
(By Sri/Smt. Prasanna V.R. & Lingaraj, Adv.,)
-Versus-
1. M/s Star Health & Allied Insurance Co. Ltd.,
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai-34,
Rep. by its Managing Director.
2. M/s Star Health and Allied Insurance Co. Ltd.,
Branch Office No.57, 3rd Floor, Double Road,
Indira Nagar, Bangalore-560 038
Rep. by its Managing Director.
(By Sri/Smt. S.Krishna Kishor, Adv.,)
……….. Respondent/s
: ORDERS:
BY SRI RAVI SHANKAR – JUDICIAL MEMBER
The complainant in complaint No.2082/2010 preferred this appeal against order dated:04/01/2014 passed by Bangalore Urban District Consumer Commission in C.C.No.2082/2010, which dismissed the complaint who claimed for medical reimbursement by virtue of the policy obtained from the respondent/company.
2. The brief facts of the complaint is that:
The complainant had obtained policy valid from 13.01.2009 to mid night of 12.01.2010 and same was renewed w.e.f 13.01.2010 to mid night 12.01.2011 vide policy No.P/141113/01/2010/003079. The mother of the complainant underwent Coronary Artery bypass grafting from 06.05.2010 to 20.05.2010 and spent Rs.4,36,849/- towards hospitalization and medical expenses, after payment made by the complainant by virtue of the policy, the complainant claimed for reimbursement of the medical expenses from the respondent/company. Apart from that, the complainant also had obtained another insurance policy from Raksha TPA Private Limited to the tune of Rs.1,00,000/-. The said Raksha TPA Private Limited reimbursed an amount of Rs.1,00,000/- out of Rs.4,36,849/-. Hence, the complainant claimed for balance reimbursement of the said amount of Rs.3,36,849/-. In spite of settlement of the claim, the respondent/company has repudiated the claim through letter dated:2806.2010 stating that the complainant has suppressed the health condition of his Mother at the time of obtaining the proposal.
3. Being aggrieved by the said repudiation, the complainant approached the District Commission alleging deficiency in service and alleged that the complainant’s Mother had taken treatment for coronary heart disease and underwent bypass surgery from 06.05.2010 to 20.05.2010, but the respondent has repudiated the claim basing on the suppression of material facts with respect to the health condition that she suffered chronic kidney disease. The disease suffered by the Mother of the complainant has no way related to the surgery taken place at Columbia Hospital and the complainant has claimed for reimbursement of the medical expenses towards bypass surgery. Hence, the repudiation made by the Opposite Parties amounts to deficiency in service and prayed for settlement/reimbursement of the amount of Rs.3,36,848/-.
4. After trial, the District Commission dismissed the complaint. Hence, the complainant filed this appeal on various grounds.
5. We have heard the arguments from both sides.
6. On going through the memorandum of appeal and documetns produced before the District Commission, there is no dispute that the policy was renewed from 13.01.2010 to mid night of 12.01.2011 vide policy bearing No.P/141113/01/2010/003079. It is also not in dispute that the Mother of the complainant underwent bypass surgery as an inpatient between 06.05.2010 to 20.05.2010 and spent Rs.4,36,849/-. It is also not in dispute that Raksha TPA Private Limited had paid Rs.1,00,000/- under another insurance policy out of Rs.4,36,849/-, the complainant had claimed for rest of the amount from Opposite Party by virtue of the policy.
7. After receipt of the claim from the complainant, the respondent/Opposite Party repudiated the claim stating that the Mother of the complainant had suffered chronic kidney disease since form two years from the date of proposal. Hence, they have repudiated the claim under the exclusion clause that the complainant has not declared the health condition of his Mother. The District Commission dismissed the complaint holding that it is a clear case of suppression of material facts with respect to the health condition of the Mother of the complainant.
8. On perusal of the proposal form, the complainant has mentioned the health condition as good and whether she has taken any treatment with respect to any ailment, has stated “NO” though the Mother of the complainant was suffering from chronic kidney disease.
9. Here, we noticed that the claim was repudiated by the Opposite Party on the ground of suppression of material facts. The said repudiation made by the Opposite Party not amounts to deficiency in service because in order to claim any medical reimbursement, the complainant has to disclose the health condition of his Mother at the time of taking the proposal irrespective of treatment taken by his Mother. We noticed here that though the Mother of the complainant had taken treatment for her heart disease and underwent bypass surgery. We consider in order to settle the claim itself, the complainant has to disclose the ailments of the insured at the time of taking the policy irrespective of treatment taken for any other diseases, but the complainant has not disclosed the health condition of the insured. We found there is no any deficiency in service on the part of Opposite Party in repudiating the claim of the complainant. The District Commission has rightly dismissed the complaint. Hence, we found no merit in the appeal. As such the appeal is liable to be dismissed. Accordingly, we proceed to pass the following:-
:ORDER:
The appeal is dismissed. No costs.
The impugned order dated:04.01.2014 passed by Bangalore Urban District Consumer Disputes Redressal Commission in C.C.No.2082/2010 is confirmed.
Send a copy of this order to both parties as well as Concerned District Commission.
Sd/- Sd/-
Member. Judicial Member.
Tss
