BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
BANGALORE (ADDL. BENCH)
DATED THIS THE 27th DAY OF OCTOBR 2022
PRESENT
MR. RAVISHANKAR : JUDICIAL MEMBER
MRS. SUNITA CHANNABASAPPA BAGEWADI : MEMBER
APPEAL NO. 556/2013
The Oriental Insurance Company Limited, Anugraha Complex, 1st Floor, New Sayyaji Rao Road, Mysore, Represented in this appeal by Regional Manager at Regional Office, 44/45, Leo Shopping Complex, Residency Road, Bangalore 50 025. (By Sri Srishaila) | ……Appellant/s |
V/s
1. | Sri P.S. Mahesh, Major, S/o Seshagiri Rao Pathangae, No. 983, 1st Stage, Vijayanagar, Mysore. (By Sri A. Sebastian) | ..…Respondent/s |
2. | M/s Raksha TPA Pvt. Ltd., No.25, Ashirvad, 1st Floor, 29th Main, 4th ‘B’ Cross, 2nd Stage, BTM Layout, Bangalore. | |
ORDER
MR. RAVISHANKAR, JUDICIAL MEMBER
1. The appellant/Opposite Party No.1 has preferred this appeal being aggrieved by the Order dt.30.11.2012 passed in CC.No.417/2012 on the file of District Consumer Disputes Redressal Commission, Mysore.
2. The brief facts of the case are as hereunder;
It is the case of the complainant is that he obtained a medical policy from the Opposite Party No.1 which was renewed subsequently. After renewal, the wife of the complainant Smt. Sapina.M.Patange was also inserted to the policy. Thereafter, she underwent medical treatment of Calculus disease and after that the complainant claimed for reimbursement of the amount spent towards medical treatment, but, the Opposite Party No.1 has repudiated the claim as the treatment taken was not covered under the policy for two years after insertion. Against which, the complainant preferred a complaint before the District Commission alleging deficiency in service.
3. After service of notice, the Opposite Parties did not appear before the District Commission, hence, they placed exparte. Later the Opposite Party No.1 filed an IA to set aside the exparte order and sworn that the notice issued by the District Commission was mixed up with other papers in the office, hence, they could not appear before the District Commission on the date of appearance, but, the said IA was rejected and exparte order was passed and allowed the complaint.
4. Aggrieved by the said Order, the appellant/ Opposite Party No.1 is in appeal. Heard the arguments.
5. The appellant submits that the District Commission failed to appreciate the terms and conditions of the policy and passed an order only considering the evidence submitted by the complainant, hence, prayed to set aside the order passed by the District Commission.
6. On going through the memorandum of appeal, certified copy of the order and documents produced before the District Commission, we noticed here that the Respondent No.1 independently had obtained the individual mediclaim policy from the appellant for a period from 29.08.2011 to 28.08.2012. Subsequently, the policy was renewed and the wife of the Respondent No.1 inserted as insured. After insertion, renewed policy was issued in the name of the Respondent No.1 including the wife of the complainant. During the policy is in force, the wife of the Respondent No.1 underwent medical treatment which was excluded in Clause-4.3 of the terms and conditions of the policy. The said treatment is not covered under the policy for two years if the person is inserted whereas the District Commission without considering the said terms and conditions have awarded the entire claim amount made by the complainant prior to giving any opinion with respect to the mediclaim policy. The District Commission ought to observe the terms and conditions of the policy. Though the appellant/Opposite Party placed exparte, the Respondent No.1 had produced the copy of the policy before the District Commission at the time of evidence and the District Commission had failed to observe the terms and conditions of the policy. Infact the terms and conditions of the policy are binding on both parties where there is an exclusion clause for particular treatment and the repudiation cannot be treated as deficiency in service. Hence, the following;
ORDER
Appeal is allowed. Consequently, the complaint is dismissed.
The amount in deposit shall be refunded to the appellant under proper identification.
Forward free copies to both parties.
Sd/- Sd/-
MEMBER JUDICIAL MEMBER
KCS*
