THE KARNATAKA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION, BANGALORE. (ADDL. BENCH)
DATED THIS THE 8th DAY OF MAY, 2023
APPEAL NO.514/2023
PRESENT
SRI RAVI SHANKAR, JUDICIAL MEMBER
SMT. SUNITA C.BAGEWADI, MEMBER
TATA AIG GENERAL INSURANCE
CO. LTD., 2nd Floor, ...Appellant/s
JP & Devi Jambukeswar Arcade,
Millers Road, Bangalore
Rep by its Legal Manager,
(By Sri.Prashanth T.Pandit, Advocate)
-Versus-
1. Sri.H.C.Raghavendra,
S/o C.Chikkanna,
Aged about 23 years,
R/at Hunnanadoddi village,
Chikkarasinakere hobli, …. Respondent/s
Madur taluk, Mandya District
Reptd by its GPS holder, Father
C.Chikkanna S/o Chikkaiah
@ Buddaiah, aged about 55 years,
R/at Hunnananadoddi village,
Chikkarasinakere hobli,
Maddur Taluk, Mandya District
2. The Superintendent/Manager
Apollo BGS Hospital, ... Respondent/s
Adichunchanagiri Road,
Kuvempunagara,
Mysore-570 023
O R D E R
BY SRI RAVI SHANKAR, JUDICIAL MEMBER
The Opposite Party in complaint No.73/2021 preferred this appeal against the order passed by the District Consumer Commission, Mandya which directed this appellant to pay an amount of Rs.1,59,188.30 towards medical claim and submits that the complainant had filed a complaint before the District Commission alleging deficiency of service in not settling the claim towards medical expenses. The complainant had obtained the TATA AIG Health Insurance Policy in the name of son of the complainant vide policy no.0238502795, Group: 309711200001428 for the period from 11-11-2020 to 10-11-2021. The son of complainant one Mr.H.C.Raghavendra had fallen down from the stairs-case and sustained some injuries. Immediately he was admitted to Apollo BGS hospital at Mysore and took a treatment. During the hospitalization, he underwent surgery on 15-6-2021 and spent Rs.1,62,794/- towards hospital expenses. Being the policy beneficiary, the complainant claimed for cashless benefits, the same was rejected. Subsequently he paid the entire hospital charges and claimed for reimbursement, the said claim was repudiated by this appellant. Aggrieved by the said repudiation, the complainant filed a complaint before the District Commission, but the District Commission without considering the real facts had allowed the complaint and directed this appellant to pay the above said amount. The notice issued by the District Commission upon the allegations was not served on them, in spite of that the District Commission placed them as exparte and the exparte order passed by the District Commission is not in accordance with law. In fact, they have repudiated the claim for the reasons on suppression of material facts and pre-existing disease. Hence submits there is no deficiency of service, the District Commission had not considered the true facts and allowed the complaint. Hence, prays for set aside the order passed by the District Commission and dismiss the complaint, in the interest of justice and equity.
2. Heard on admission.
3. On perusal of the certified copy of the order and memorandum of appeal, we noticed that, the complainant had availed TATA AIG Health Insurance Policy bearing policy No.0238502795, Group: 309711200001428 which is valid from 11-11-2020 to 10-11-2021. It is noticed that the son of the complainant underwent surgery due to accidental fall from the stairs and surgery took place on 15-6-2021. The complainant had spent nearly Rs.1,62,794/- towards hospitalization charges. There afterward we noticed that after issuance of notice, this appellant in spite of service of notice has not appeared before the District Commission. Whereas in the memorandum appeal, this appellant had submitted that the notice was not served at all on them the said plea was not acceptable. The appellant not shown any valid reasons for not appearing before the District Commission in order to participate and take defence of the allegations made by the complainant, the appellant is so negligent in not appearing before the District Commission.
4. The learned advocate for appellant submits that the claim was repudiated basing on the non disclosure of material facts that the complainant had suppressed the material facts willfully and knowingly. Therefore there is no deficiency of service on their part and submits that the complainant is not entitled get any claim as per the policy terms and conditions. But the appellant had not reflected any material facts in the appeal memo that what kind of material fact was suppressed by the complainant at the time of taking the policy. The appellant failed to establish that son of the complainant had suppressed any material facts either before the District Commission or before this Commission. In the absence of any materials, we cannot hold that the repudiation is valid one. The District Commission after appreciating the evidence produced by both complainant and hospital had allowed the complaint and directed the appellant to pay an amount of Rs.1,58,188.30. According to us, the order passed by the District Commission is in accordance with law, we found it is clear deficiency of service on the part of the Opposite Party in not settling the genuine claim of the complainant. The appellant has not shown any valid reasons for repudiation of the claim of the complainant as such no interference is required. The order passed by the District Commission is upheld. Accordingly, the appeal is dismissed. Hence, we proceed to pass the following:-
O R D E R
The appeal is dismissed. No order as to cost.
The amount in deposit shall be transmitted to the concerned District Commission to pay the same to the complainant.
Send a copy of this order to both parties as well as Concerned District Commission.
Member Judicial Member
