Date of Filing :22.05.2024

 Date of Disposal :03.12.2024

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

DATED:03.12.2024

PRESENT

Mr K B. SANGANNANAVAR: JUDICIAL MEMBER

(DIST. & SESSIONS JUDGE (R)

Mrs DIVYASHREE M: LADY MEMBER

APPEAL No.1307/2024

Star Health and Allied Insurance Co. Ltd.,

No.184/82, 2^nd and 3^rd Floors

Above IDBI Bank

Dr. Rajkumar Road

Jaganahalli, 2^nd Block

Rajajinagar

Bangalore-560 010

Rep. by its Manager

(By Mr Janardhan Reddy, Advocate)                                     Appellant                                   Appellant

                                                 -Versus-    

Sri K N Prakash

Aged about 70 years

R/at 57, 6^th Cross

Basaveshwarnagar

Shaktiganapatinagar

Bangalore-560 079                                                          Respondent

(By Mr S B Chandrashekaraiah, Advocate)  

-:ORDER:-

Mr. K B. SANGANNANAVAR: JUDICAL MEMBER:

1.       This is an Appeal filed under Section 41 of Consumer Protection Act, 2019 by OP1 aggrieved by the Order dated 31.10.2023 passed in Consumer Complaint No.230/2022 on the file of III Additional District Consumer Disputes Redressal Commission, Bengaluru (for short, the District Commission).

2.       The Parties to this Appeal will be referred to as their rank assigned to them by the District Forum.

3.       The Commission examined the impugned order, grounds of Appeal, Appeal papers and records of District Forum.

         Now the point that arises for consideration of this Commission would be: 

          Whether impugned order dated 31.10.2023 passed in CC No. 230/2022 does call any interference of this Commission for the grounds set out in the Appeal Memorandum?

4.       It is an undisputed fact that OP1 had issued insurance policy in favour of son of the complainant Mr P Shreyas and the complainant is also insured in the said policy.  These policies are marked as Ex-P16 and 17.  During 2016, complainant was admitted to Fortis Hospital and at that time, the Doctors suspected acute pancreatitis, after various investigations no treatment was given and Doctors were unable to diagnose any specific reason for stomach pain and finally found pain was only due to viral infection and complainant was discharged without any diagnosis.  The complainant had claimed Rs.5,52,270/- under two policies.   However, insurer OP1 did not reimburse the claim on the ground of non-disclosure of pre-existing disease and as a result complainant alleged against OP1, rendered deficiency in services, since repudiated his claim by issuing an endorsement vide Ex-P24A stating that policy in respect of the complainant stands cancelled w.e.f 21.05.2022. The policy came to be cancelled by OP1 due to non-disclosure of pre-existing disease. In this regard, the complainant had also submitted necessary documents and all the clarification sought by OP1. However, it is the specific defense of OP1 that from the medical records dated 08.02.2016 the insured/patient was diagnosed as Ischemic heart diseases coronary artery disease single vessel disease which was prior to inception of medical insurance policy and in view of condition No.6 of the policy, the insurer is not liable to indemnify any payment and unable to settle the claim. 

5.       Learned counsel for Appellant/OP1 submitted that in Writ Petition No.14346/2021 (GM-RES), the Hon’ble High Court of Karnataka in the case between Mrs. Jaya Elizabeth Mathew and another Vs Insurance Ombudsman for the State of Karnataka and another on 21.10.2022, held no fault can be found with the repudiation and disallowing the claim. In our view it was decided on the facts of the case stated in the said writ petition, wherein the Petitioners are wife and husband, they having desire of building a house opted for home loan through HDFC ERGO General Insurance Company Limited.  The loan came with ‘Home Suraksha Plus’ dated 29.04.2017 and was to be a period of 5 years from 29.04.2017 to 28.04.2022. The policy covered major medical illness and procedures to an amount of Rs.56,87,368/- jointly for both the petitioners. On 10.08.2020, it appears that the Doctors at Vikram Hospital diagnosed the 1^st Petitioner to be suffering from Multiple Sclerosis and started treatment immediately. After the treatment, the insurance claim was made on the strength of the insurance coverage that was given by Insurance Company in its policy dated 29.04.2017. The claim was repudiated by communicating dated 14.12.2020 on the ground that the 1^st Petitioner was diagnosed to be suffering from multiple sclerosis form 27.03.2017 and the ailment was a pre-existing ailment which had not been divulged by the Petitioners while filling the form claiming such insurance. The insurance Ombudsman by an order dated 29.03.2017 affirms repudiation of the claim of the Petitioners and also hold that the Petitioners were guilty of their non-disclosure of information about serious illness notwithstanding it being in their knowledge. 

6.       However, the facts on hand in this case  are entirely different with the policy obtained by Petitioner and his son is for the period from 29.07.2020 to 28.07.2021 was renewed from 29.07.2021 to 28.07.2022 and it is found from enquiry that during the year 2016 when the complainant was admitted at Fortis Hospital and though at the time of admission, the Doctors suspected acute pancreatitis, after various investigation, no treatment was given and doctors were unable to diagnose any specific reasons for stomach pain and finally found pain was only due to viral infection  and ultimately discharged without any diagnosis.  It is also come in the enquiry, complainant was admitted to Narayana Hospital during 24^th to 30^th April 2021, when the second wave of Covid-19 was in existence and in the RTPCR test it was shown positive result and after discharge from the hospital, he had submitted the claim before OP1 and also renewed the policy for the year 29.07.2020 to 28.07.2021 and in such circumstances, District Commission rightly held cancellation of the policy   is with effect from 21.05.2022,  won’t come  in the way of the petitioner to claim reimbursement for the above said period and rightly held complainant is entitle for reimbursement for a sum of Rs.5,52,270/-, which in our view, does not call for any interference of the Commission for the ground set out in the Appeal memo, in particular on the ground of non-disclosure of pre-existing disease at the time of obtaining the policy, since nothing is placed to rebut that complainant had failed to disclose the pre-lexisting decease prior to obtaining the policy. In such view the case cited supra relied  on by learned counsel for Appellant did not come to the assistance of the insurer to justify repudiation of the claim submitted by complainant, since facts herein would become distinguishable to the facts in the said case.  In such view of the matter, we proceed to dismiss the Appeal with no order as to costs.

7.       Amount in deposit is directed to be transferred to the District Commission for the needful.

8.       Send copy of this Order to the District Commission and parties concerned for their information.

                Lady Member                    Judicial Member

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