Date of filing:14.08.2017

                                                   Date of Disposal:15.03.2023

BEFORE THE KARNATAKA STATE CONSUMR DISPUTES REDRESSAL COMMISSION, BENGALURU (PRINCIPAL BENCH)

DATED: 15^th Day of March 2023

PRESENT

HON’BLE Mr. JUSTICE HULUVADI G. RAMESH: PRESIDENT

Mr K. B. SANGANNANAVAR: JUDICIAL MEMBER

Mrs DIVYASHREE M: LADY MEMBER

APPEAL NO. 1629/2019

O R D E R

BY HON’BLE Mr. JUSTICE HULUVADI G RAMESH : PRESIDENT

1. This is an Appeal filed under Section 15 of Consumer Protection Act, 1986 aggrieved by the impugned order dated 04.10.2019 passed in CC/738/2017 by District Consumer Disputes Redressal Forum, Belagavi. (herein after referred as District Forum and the parties arrayed as in the consumer complaint).

2. Commission examined grounds of appeal, impugned order, appeal papers and heard learned counsel for appellant.

3. It is undisputed fact that complainant/respondent had taken Health Insurance Policy for sum assured of Rs.4,00,000/- from OP/appellant for the period from 10.01.2017 to 09.01.2018. It is also not in dispute that complainant/respondent was admitted to hospital on 28.07.2017 to 02.08.2017 i.e., well within the policy period.  The only dispute is related to the repudiation of claim from OP/appellant for remaining balance of the bill amount paid by complainant/respondent towards treatment. Admittedly complainant/respondent had undergone PTCA with stenting to RCA and PTCA with stenting to LAD in KLES Dr.Prabhakar Kore Hospital and Medical Research Centre, Belagavi, which falls within the network of hospitals of the OP-Insurance Company/appellant.  The final bill raised by the said hospital during the hospitalization of complainant/respondent was Rs.2,67,977/- which according to complainant/respondent was within the insured amount of Rs.4,00,000/-.  It is the specific contention of OP/appellant is that the treatment undergone by the complainant/respondent was for Ischemic Heart Disease which is said to be the pre-existing disease and as per policy terms and conditions much less Exclusion clause C-1 and D Condition Clause 16, the OP/appellant settled the claim of the complainant/respondent considering @ Rs.1,00,000/- being the sum insured with cumulative bonus of 10% thus in total @ Rs.1,10,000/-. 

4. It is pertinent to note here that complainant/respondent had obtained first time policy with OP/Appellant in the year 2006 for the period of one year for Rs.1,00,000/-. Since then complainant/respondent renewed the said policy continuously for the past several years.  In the year 2016 when complainant sought for renewal of the said health insurance policy for the sum insured plan for Rs.1,00,000/- was withdrawn by the OP Insurance Company and consequently OP Insurance Company offered the complainant to choose other plans, amongst its available similar health insurance products. Accordingly, complainant/respondent chosen Health Guard Individual Policy for the sum insured of Rs.4,00,000/- upon payment of extra premium amount, which is treated as the fresh policy by the OP Insurance Company.

5. Further to be noted herein that complainant/respondent had underwent Coronary Angiography on 31.07.2017, which revealed CAD-Tripple Vessel Disease which is the heart problems caused by narrowed heart arteries. We have to observe herein that Ischemic Heart Disease are also called as Coronary Heart Disease (CHD) or Coronary Artery Disease, is the term given to heart problems caused by narrowed heart (Coronary) arteries that supply blood to the heart muscle, which tend to be chronic or long terms medical illness. As per terms and conditions of the policy especially Exclusion clause C1 –

“Benefits will not be available for any pre-existing condition, ailment or injury, until 48 months of continuous coverage have elapsed, after the date of inception of the first Health Guard Policy with us.  The above exclusion C1 shall cease to apply if you have maintained a Health Guard Policy with us for a continuous period of a full 04 years without break from the date of your first Health Guard Policy with us.  In case of enhancement of sum insured this exclusion shall apply afresh only to the extent of the amount by which the limit of indemnity has been increased (i.e. enhance sum insured) if the policy is a renewal of Health Guard Policy without break in over.”

     Thus the insured/complainant had obtained policy for the period from 10.01.2016 to 09.01.2017 for Rs.4,00,000/-, being the fresh policy and as per the terms and conditions of the policy especially exclusion clause C1 the sum insured of Rs.1,00,000/- with cumulative bonus of Rs.10,000/- was rightly reimbursed to the hospitalization expenses by OP/appellant.

6. The Forum below erred in passing the impugned order stating that respondent/complainant had renewed her health insurance policy in the year 2016.  But fact remained that respondent/complainant had taken the fresh Health Guard Individual Policy from the OP/appellant in the year 2016 as the existing policy which the complainant/respondent had taken was withdrawn by the OP/Appellant company. Further the Forum below misdirected by themselves to record findings against appellant/OP and also without considering the terms and conditions of the policy especially exclusion clause C1 directed OP Insurance Company to reimburse Rs.1,99,930/- to the complainant with interest @ 09% p.a. from the date of filing of complaint, till realization, which in our view is contrary to facts and law and does call for an interference of this Commission.  In such view of the matter, Commission proceed to allow the appeal.  Consequently, set aside the impugned order passed in CC/738/2017 by District Consumer Disputes Redressal Commission, Belagavi.  As a result CC/738/2017 is dismissed with no order as to cost.

7. The Amount in deposit is directed to be transferred to the appellant with proper identification by his advocate.

8. Send a copy of this Order to the concerned District Commission and parties to the appeal.

Lady Member             Judicial Member                President

*GGH*