BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE.
DATED THIS THE 8th DAY OF JUNE 2021
PRESENT
MR. RAVISHANKAR : JUDICIAL MEMBER
MRS. SUNITA CHANNABASAPPA BAGEWADI : MEMBER
APPEAL NO. 972/2017
Dr. M.N. Manjappa, Aged about 72 years, S/o Late N. Ningappa, R/at Door No.474, 2nd Main, 6th Cross, 1st Block, Ramakrishna Nagar, Mysore. (By Sri K. Ramagopal & Sri M. Lingaraj) | ……Appellant/s |
V/s
1. | Star Health and Allied Insurance Company Limited, Corporate & Reg. Office: No. 1, New Tank Street, Valluvr, Kottam High Road, Nungambakkam, CHENNAI 600 004, Rep. by its Chairman & Managing Director. | …Respondent/s |
2. | The Branch Manager, Star Health and Allied Insurance Company Limited, Office: Lakshmi Arcade, 1st Floor, No.14, 8th Cross, 4th Main, Kamakshi Hospital Road, Saraswathipuram, Mysore 570 009. | |
3. | Sri C. Ramesh, Representative of Star Health and Allied Insurance Company Limited, Office: Lakshmi Arcade, 1st Floor, No.14, 8th Cross, 4th Main, Kamakshi Hospital Road, Saraswathipuram, Mysore 570 009. (By Sri S. Krishna Kishore) | |
ORDER
BY SRI RAVISHANKAR, JUDICIAL MEMBER
1. The appellant/complainant has preferred this appeal being aggrieved by the Order dt.18.02.2017 passed in CC.No.1188/2016 on the file of District Consumer Disputes Redressal Commission, Mysuru.
2. The facts leading to the appeal are as hereunder;
It is the case of the complainant that he had obtained Health Insurance Policy from the Opposite Party Company in the year 2011 and the same was renewed without any default till 2016 and the complainant had paid regular premium towards the policy. Such being the case, the complainant had underwent replacement of knees in the year 2015 at Ganga Medical Centre & Hospital (P) Ltd., Coimbatore. He was treated as inpatient from 10.10.2015 to 24.10.2015 and spent Rs.3,62,730/- during hospitalization for replacement of his both knees. The Opposite Party at the time of admission gave an authorization to the said hospital to conduct operation and indemnified to pay the expenses, but, at the time of discharge, the Opposite Party denied to pay the hospitalization charges. Hence, he filed a complaint before the District Commission alleging deficiency in service on the part of the Opposite Party in not settling the claim.
3. The Opposite Party Company appeared through their counsel and contended in their version that the complainant had pre-existing disease and he had underwent angioplasty on 03.05.2011 and the complainant had suppressed the said material facts at the time of taking the policy. Hence, the Opposite Party Company prayed to dismiss the complaint.
4. After trial, the District Commission dismissed the complaint.
5. Being aggrieved the said Order, the appellant/ complainant is in appeal. Heard both parties.
6. The learned counsel for appellant vehemently argued that the complainant though underwent angioplasty on 03.05.2011 had not claimed any amount towards the said ailment from the Opposite Party and he claimed only for the reimbursement of medical expenses of Rs.3,62,730/- which is spent towards replacement of his both knees at Ganga Medical Centre & Hospital (P) Ltd., Coimbatore. Whereas the learned counsel for the respondent had submitted that the complainant had not disclosed the said treatment at the time of proposal. Hence, under the clause of suppression of material facts, they have repudiated the claim and submits that there is no deficiency in service.
7. On going through the memorandum of appeal, certified copy of the Order and documents, we noticed that the complainant had obtained a Health Insurance Policy way back in the year 2011 which was continuously renewed without any default. The same is admitted by the respondent. The policy is very clear that once it was renewed continuously for more than four years without any default, even the pre-existing diseases are also going to be covered, therefore, the said disease need not be informed to the Opposite Party. Under these circumstances, we found that there is deficiency in service on the part of the respondent in repudiating the claim towards the knee replacement and not towards the angioplasty. As such, the complainant is entitled to get a reimbursement of the medical expenses. The District Commission has made an error in not considering the policy terms and conditions at the time of disposal of the complaint. Hence, the order passed by the District Commission is hereby set aside and proceed to pass the following;
ORDER
The appeal is allowed.
The respondent/Opposite Party/s is directed to pay the eligible medical expenses to the complainant spent towards knee replacement.
The Opposite Party/s is further directed to pay a sum of Rs.50,000/- towards compensation and Rs.10,000/- towards litigation expenses to the complainant.
The Opposite Party is granted 30 days time from this date to comply the order. In default, the amount of medical expenses shall carry interest at 6% from the date of order of the complaint i.e. 18.02.2017, till realization.
Forward free copies to both parties.
Sd/- Sd/-
MEMBER JUDICIAL MEMBER
KCS*
