BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE

(ADDL. BENCH)

DATED THIS THE 4^th DAY OF JULY 2022

PRESENT

MR. RAVISHANKAR                           : JUDICIAL MEMBER

MRS. SUNITA CHANNABASAPPA BAGEWADI :      MEMBER

APPEAL NO. 48/2018

V/s

ORDER

MRS. SUNITA CHANNABASAPPA BAGEWADI, MEMBER

1.      The appellant/complainant has preferred this appeal being aggrieved by the Order dt.28.09.2017 passed in CC.No.2062/2015 on the file of 1^st Additional District Consumer Disputes Redressal Commission, Bangalore.

2.      The brief facts of the case are as hereunder;

It is the case of the complainant that his son Harish Kumar taken the Health Insurance Policy bearing No.10046184 under the plan name CARE in the name of his father Sri S. Kumar and Mother Smt. Girija Kumar from the Opposite Parties by paying premium amount of Rs.23,920/- for an assured sum of Rs.5,00,000/- and the policy valid from 24.10.2013 to 24.10.2014.  The complainant further alleged that the Opposite Parties offered the benefits to the insured such as hospitalization expenses, pre-hospitalization and post-hospitalization expenses, ambulance cover, organ done cover, domiciliary hospitalization, health checkup, second opinion charges and no claim bonus also offered tax benefits.  The complainant took treatment for gastro problem, but, it was not cured and the doctor who treated him advised biopsy of ulcer and x-ray of chest.  On 20.06.2014 he visited Health Care Global Enterprises and done NUSG of Thyroid and Microscopy, it was found that moderately differentiated squamous cell carcinoma left lateral tongue and MRI Neck was done on 24.06.2014.  The complainant further alleged that he took treatment for Carcinoma Left Lateral Border of Tongue and spent Rs.2,38,262.17 for which the complainant submitted insurance claim to the Opposite Parties, but, surprisingly the Opposite Parties repudiated the claim vide letter dt.08.08.2014 on the ground of non-disclosure of material information at the time of proposal, but, the complainant further alleged that the doctors of Opposite Party have done medical checkup while issuing the policy.  Hence, the complaint.

3.      After issuance of notice, the Opposite Parties appeared through their counsel and filed their version.  In the version the Opposite Parties contended that the son of the complainant took the medi-claim insurance policy vide policy bearing No.10046184 on 24.10.2013 for himself and to his parents for an assured sum of Rs.5,00,000/-.  It is contended that on 24.06.2014, the complainant requested the Opposite Parties for cashless facility for the treatment at HCG Hospital and submitted the pre-authorization form and the Opposite Parties have approved cashless facility for an amount of Rs.90,000/- on 28.06.2014, however, the same was repudiated due to non-disclosure of facts since the insured never disclosed about diabetes mellitus at the time of obtaining the policy.  The Opposite Parties denied all the allegations made in the complaint and the complaint filed with malafide intention, hence, prayed to dismiss the complaint.

4.      After trial, the District Commission partly allowed the complaint and directed the Opposite Parties jointly and severally liable to pay Rs.2,38,000/- to the complainant with interest at 7.5% p.a. from the date of complaint, till realization along with costs.

5.      Aggrieved by the said Order, the appellants/ Opposite Parties are in appeal.  Heard the arguments.

6.      Perused the appeal memo, order passed by the District Commission and materials on record, we noticed that it is an admitted fact that the son of the respondent S.Kumar obtained mediclaim insurance policy for himself and for his parents commencing from 24.10.2013 to 23.10.2014 for an assured sum of Rs.5,00,000/- by paying yearly premium of Rs.23,920/-.  It is also not in dispute that the father of the complainant underwent surgery for ulcer in left lateral tongue since 2-3 months and underwent surgery for left hemithyroidectomy + Wide Local Exision of Tongue Lesion + Left modifies Neck Dissection and spent Rs.2,38,262=17. 

7.      Perused the order passed by the District Commission.  We noticed that the appellant contended in the lower court that as per clause 6.1 and 6.2 of policy, the respondent has suppressed the material facts about diabetes.  Hence, the insurance company shall have no liability to pay the amount which was spent by the respondent on treatment of his father and premium shall be forfeited.

8.      Considering the facts, the District Commission held that the appellants issued the policy after examination of the respondent by their doctors and if the respondent is diabetic, it revealed at that time only.  Moreover, the appellants did not examine the expert doctor or filed any affidavit of expert doctor to show that the respondent has diabetic from past seven years and due to diabetic only the complainant underwent such surgery. 

9.      We observed in numerous judgements of Hon’ble Supreme Court of India that diabetic is not a disease.  It is a life style disease, but, it is a common physical disorder and no ground to deny.  Moreover, object of lying up mediclaim policy has to seek help in respect of sudden illness or sickness.  Hence, in our opinion, if the appellant alleged that the respondent has suppressed the material facts, it is their duty to prove it, but, the appellant has not produced any materials to show that the respondent has diabetic from past seven years and underwent surgery due to diabetic.  Hence, the repudiation of the claim by the insurance company was not in accordance with law.  Hence, considering the facts and discussion made here, we are of the opinion that the order passed by the District Commission is just and proper.  No interference is required.  Hence, the following;

ORDER

The appeal is dismissed.

Forward free copies to both parties.

    Sd/-                                                          Sd/-

MEMBER                                   JUDICIAL MEMBER

KCS*