BEFORE THE ADDITIONAL BENCH DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT

MYSURU.

Consumer Complaint (C.C.)No. 1468/2016

Complaint filed on 22.09.2016

Date of Judgement.27.11.2017

PRESENT                      :         1. Shri Ramachandra  M.S.,  B.A., LL.B.,

                                                   PRESIDENT

2. Shri  Thammanna,Y.S., B.Sc., LL.B., 

                                       MEMBER

Complainant/s       :                Prakash.K

                                                Aged 34 years

                                                # 53, 20^th cross, 1^st main Jayanagar,

                                                Mysuru-570014.

(Inperson)

V/s

Opponent        /s             :       1.SBI General Insurance Company Ltd.,

                                                 Rukmini Plaza, 1^st floor, 1-A Srirampura

                                                 Main road, Vivekananda Circle, 80ft Road,

                                                 Madhuvana Layout, Srirampura,

 Mysuru-23.

2.SBI General Insurance Company Ltd.,

                                                Grievance Redressal Officer, 101,201,301,

                                                Nartaj Junction of Western Express Highway

And Andheri Kurla road, Andheri East,

Mumbai-69.

(Sri. Kenche Gowda Patel., Advocate)

           SHRI RAMACHANDRA . M.S.,

           PRESIDENT

JUDGEMENT

The complainant filed the complaint Under Section 12 of Consumer Protection Act, 1986 against the opposite party seeking for relief of policy claims  and prayed for relief.

2. The brief facts of the complainant that the above case took mediclaim policy bearing no. 2847381 for a period of 1 year commencing from 22.04.2015 to 21.04.2016 during the currency of the policy complainant fell ill and took treatment for Renal Biopsy at Apollo Hospital and submitted record to the hospital for getting cashless benefit from op accordingly hospital Authority submitted records to op after treatment all bills have been submitted to the op. The op repudiated the claim of the complainant to the tune of Rupees 40,000/-hence this complainant is filed claiming the said amount due to the deficiency of service by the op. In repudiated the complainant claim.

3. Notice to the opposite party duly served represented by counsel filed version. 

4. The complainant and opposite party filed chief examination affidavit and documents in support of contention written arguments filed, oral arguments heard, reserved for orders.

5. Heard arguments.

6. The points that arise for our consideration are;

1. Whether the complainant proves that there is deficiency in service on the part of opposite party by not settling insurance claim amount and thereby he is entitle for the relief sought?

2. What order?

7. Our answer to the above points is as follows;

1. Point No.1: In the Negative.
2. Point No.2: As per final order for the following;

REASONS

8 . Point No.1:-  That the complainant has taken the medi-claim policy from opposite party company vide # 284738 for a period of one year commencing from 22.04.2015 to 21.04.2016. Further during the validity of said policy he fell ill and took treatment for Renal Bio PSY at Apollo Hospital, Mysore and also submitted records for cash less benefit from opposite party and the hospital authority submitted records to opposite party thereafter opposite party has repudiated the claim of Rs. 40,000/- the ground of opposite party for refusal to settle the claim is that since there is exclusion clause in terms and conditions of which will not permit the opposite party to entertain the claims of complainant. Here the dispute between two parties is whether the repudiation made by opposite party is valid if so the claim of complainant cannot considered.

9. Further that the complainant at the time of taking health insurance policy from opposite party company has knowingly agreed and signed the application and also to the concerned terms and conditions of policy by accepting the same. Once it is signed by him there exists a contract between complainant and opposite party company. When any one of the terms and conditions of policy, barred the complainant from claiming the insurance claim amount  these act has to be termed as there is no violation of terms and conditions of policy by the opposite party. When such is the case, there cannot be any deficiency in service on the part of opposite party company.

10. Further it is apparent that the terms and condition at para 3 in page 8  in the policy issued by opposite party has been clearly mentioned that the alleged treatment for NEPHRATIC for which renal BioPSY was done which is not covered under the policy during the first  year of the policy as mentioned in the exclusion clause of the policy. When these terms and condition is agreed and signed by complainant is legal bound by the same. When such being the case the opposite party company has rightly repudiated the claim of complaint for that  reason the rejection of complaint claim by the opposite party cannot be termed as deficiency in service, it is prima facie from the above facts and documents produced that the complainant is not entitle for the relief claimed and at the same time. The act of opposite party is justified and repudiation of complainant claim held and proper and correct.  For the same the complainant claim is liable to be dismissed.

11.Further the complainant has failed to prove his claim beyond reasonable doubt and also failed to prove deficiency in service on the part of opposite party. For that reason the complaint is dismissed.. In view of the above observation the point no 1 we answered in the Negative.

12. From the above discussion we hereby proceed to pass the following :-

ORDER

1. The complaint is hereby dismissed.
2. Give the copies of this order to the parties, as per Rules.

(Dictated to the stenographer transcribed , typed by her, transcript corrected by us and then pronounced in open court on the 27^th November  2017)  

Shri Thammanna Y.S.,                                 Shri Ramachandra M.S.,    

Member.                                                          President.