THE KARNATAKA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION, BANGALORE. (ADDL. BENCH)
DATED THIS THE 11th DAY OF JUNE 2021
PRESENT
SRI RAVI SHANKAR – JUDICIAL MEMBER
SMT. SUNITA C.BAGEWADI - MEMBER
APPEAL NO. 306/2015
Sri. Vadakkath Suresh Kumar
S/o Late CNK Menon,
Aged about 54 years,
R/at No.302, 10th Main,
6th Block, Koramangala,
Bengaluru-95.
…….Appellant/s.
(By Shri/Smt Shetty and Hegde Associates, Adv.,)
-Versus-
Royal Sundaram Alliance
Insurance Company Limited,
Corporate Accident and Health
Claim Department, Desshbandu Plaza,
Whites Road, Chennai-14,
Represented by its Director.
Branch office at: Sy.No.26/2,
Kadubisisnahalli Village,
Varthur Hobli,Belundur Post,
Bangalore.
……….. Respondent/s
(By Shri/Smt Manoj Kumar M.R., Adv.,)
:ORDERS:
BY SRI.RAVI SHANKAR - JUDICIAL MEMBER
The appellant/complainant preferred this appeal against order dated:02/02/2015 passed by Bangalore Urban IV additional District Consumer Commission in C.C.No.580/2013 which dismissed the complaint alleging deficiency in service against the Opposite Party in not settling the health claim and submits that he had initially obtained health Shield Gold policy bearing No.HE00005811000107 for Rs.2,00,000/- in the year 2004 and the premium was Rs.8,286/- and he was renewing the said policy periodically. Accordingly after receipt of the premiums, the Opposite Party also issued the policy to that effect. He renewed the policy till on 29/02/2012. Such being the case, on 27.01.2012 the complainant visited to St.Johns Hospital and underwent FNAC test, wherein the report revealed that the appellant is suffering from Metastatic Squamores Cell Carunama” and he was advised to further test. Accordingly on 30.01.2012 the complainant visited P.D.Hinduja National Hospital and Medical Research Centre at Mumbai and consulted Dr.Sultan Pradhan (Oncologist Surgeon), wherein they suggested the complainant to undergo surgery immediately. Accordingly, the complainant admitted to Prince Ali Khan Hospital at Mumbai and underwent the surgery on 06.02.2012 and discharged on 12/02/2012 and has incurred total expenses of Rs.5.00 Lakhs towards medical treatment. Being the beneficiary of the policy, the complainant claimed for reimbursement of the said amount after submission of the required documents. The Opposite Party has not settled the claim as per Clause-25 of the health insurance policy. The complainant had claimed 3.20 lakhs under the said policy. But without any valid reasons, the Opposite Party had repudiated the claim and therefore he preferred the complaint alleging deficiency in service against the Opposite Party. But the District Commission without considering the relevant documents and facts of the complaint has dismissed the complaint for the reason that there is exclusion Clause in the policy for reimbursement of medical expenses which were incurred towards cancer which was caused due to excess usage of Tobacco, hence, not satisfied with the said order, the appellant before this Commission.
2. Heard arguments from both sides.
3. On going through the memorandum of appeal, certified copy of the order and documents produced by both the parties, we noticed that the complainant had obtained two policies bearing No.HE00005811000107 and HE0008944500102. The complainant was renewed the said policies since from 2004 to 2012. The policy was in force after the claim made by the complainant. The Opposite Party has settled the claim to the tune of Rs.72,000/- under the policy bearing No.HE000089445000102, the same was accepted by the complainant. But the Opposite Party has repudiated the claim under the other policy stating that the said ailment was not covered as per the revised terms and conditions of the policy.
4. The learned Advocate for complainant vehemently argued that the complainant is renewing the policy since from 2004 and the Opposite Party as and when the policy renewed, they are using to send policy conditions to him, but for the year 2012 they have only sent a cover note and not sent any terms and conditions of the policy. Hence, submits they are liable to settle the claim under the said policy to the extent of Rs.3,32,000/-.
5. On going through the policy terms of the revised policy for the year 2012, it is clear that the surgery underwent by the complainant was not covered as because it was due to too much usage of Tobacco and the was noted by the Doctors who were treated him. The only contention taken by the complainant is that he had no knowledge about the revised terms and conditions of the policy. But we are not accepting the said arguments submitted by the complainant. Because the complainant stick on to the terms and conditions of the policy which was initially issued in the year 2004. The complainant also admitted that it was renewed as and when he was paying the premium and terms and conditions were issued to him, but the Opposite Party had not issued the terms and conditions of the policy for the year 2012 and had issued only policy cover note. Even though he had no knowledge about the terms and conditions of the revised policy, the claim cannot be settled because the terms and conditions are binding on both the parties. The Opposite Party cannot go beyond the terms and conditions and settled the claim, whereas they have settled the claim under other policy, where there was no exclusion Clause. We found there is no any illegality or irregularity in the order passed by the District Commission. Hence, 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:02/02/2015 passed by the Bangalore Urban District Consumer Commission in C.C.No.580/2013 is hereby confirmed.
Return the LCR forthwith to the concerned District Commission.
Send a copy of this order to both parties as well as Concerned District Commission.
Member. Judicial Member.
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