Date of Filing:23.05.2018
Date of Disposal :19.12.2023
BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU (PRINCIPAL BENCH)
DATED:19.12.2023
PRESENT
HON’BLE Mr JUSTICE HULUVADI G RAMESH : PRESIDENT
Mr K BSANGANNANAVAR: JUDICIAL MEMBER
Mrs DIVYASHREE M:LADY MEMBER
APPEAL No.777/2018
Mr Paramjit Singh
S/o Late Avatar Singh
Aged about 65 years
Residing at No.E-503
Daffodils Tower-3
Adarsh Palm Retreat
Behind Intel, Outer Ring Road
Bengaluru-560 103 Appellant
(By Mr B S Govinda Swamy, Advocate)
-Versus-
The Branch Manager
National Insurance Company Ltd.,
No.20/21, K G Road Branch
1st Main Road, Gandhinagara
Opp: Indian Overseas Bank
Bengaluru -560 009 Respondent
(By Mr Janardhan Reddy, Advocate)
:ORDER:
Mr JUSTICE HULUVADI G RAMESH : PRESIDENT
1. This Appeal is filed under Section 15 of Consumer Protection Act 1986 by the Complainant, aggrieved by the Order dated 23.04.2018 passed in Consumer Complaint No.46/2017 on the file of I Additional District Consumer Disputes Redressal Forum, Bangalore (hereinafter referred to as District Forum).
2. Heard the arguments of Learned Counsels on record.
3. The District Forum after enquiring into the matter, Dismissed the Complaint with an observation that there is no evidence placed on record and the Sales Executive, according to the Complainant, who assured him that he will get the benefit of the earlier Policies has not been named and examined before this Forum. Even there is no written documents or endorsement/undertaking issued or given by him to show that in fact he has promised to get the benefit of the earlier policies. When such being the case, it cannot be believed that in fact he has promised to get the benefits of the earlier policies. Even assuming for the moment that the said assurances has been given by the said sale executive, it has no sanctity in view of the provisions of the Policy.
4. Being not satisfied with the Order of the District Forum, the Complainant is in Appeal.
5. Being not satisfied with the Order of the District Forum, the Complainant is in Appeal.
6. According to complainant, he purchased a new Policy as per the advice and assurance of the Sales Executive of OP, with an assurance to the effect that exemptions with regard to pre-existing disease will be covered in the new Policy. On 10.06.2016, he got admitted to SAKRA Hospital, Bellandur, Bengaluru as an in-patient and was Discharged on 13.06.2016, after spending a sum of Rs.4,41,289/-towards In-patient treatment, where after he made a claim to the OP towards reimbursement of the same, but, OP rejected the Claim as per Clause 4.3 of the Policy.
7. OP admitted the payment of Rs.38,218/- for issuance of a new Insurance Policy covering the period from 26.02.2016 to 25.02.2017 and also admitted the Claim made by the Complainant to an extent of Rs.4,41,289/- being the Hospitalisation charges for the medical treatment taken in SAKRA Hospital, Bengaluru. OP had taken a stand for rejection of the Claim, as per policy condition Clause 4.1 and 4.3 of the Policy, regarding pre-existing disease and the Claim is treated as a fresh one under the new Policy. Further, had taken a stand that, the Complainant had undergone surgery for Coronary Artery disease which was pre-existing and same cannot be waived even though the Complainant has obtained the Policy for the last four previous years. Further, their Sales Executive has not at all given any assurance to the Complainant that the pre-existing disease would be covered by obtaining a new Policy.
8. It is not in dispute that the Complainant had obtained a Medi-Claim Policy from OP for the period 26.06.2011 till 25.06.2015; renewed the Policy by paying premium every year regularly and it is also not in dispute that he purchased the new policy on 26.02.2016 from OP by paying premium of Rs.38,218/- after lapse of 9 months. During the subsistence of the Policy, Complainant underwent Coronary Artery disease on 10.06.2016 within 4 months of obtaining the policy at SAKRA Hospital, Bellandur, Bengaluruas in-patient by spending an amount of Rs.4,41,289/-as Hospital Charges and was Discharged on 13.06.2016.
9. The main contention of the OP is that the purchase of Policy on 26.02.2016 treated as New Policy and there is a break in the continuity of the Policy, complainant cannot be given the benefit of waiving the pre-existing disease under clause 4.1 and 4.3 of policy. The clause 4.1 and 4.3 of the Mediclaim Policy reads as hereunder:
4.1 Pre-existing disease
All pre-existing diseases when the cover incepts for the first time until 48 months of continuous coverage has elapsed. Any complication arising from pre-existing ailment/disease/injuries will be considered as a part of pre-existing health condition or disease.
To illustrate if a person suffering from either hyper-tension or Diabetes or both at the time of taking the Policy, then Policy shall be subject to the following exclusions.
4.3 Specified waiting period
i. One year waiting period.
ii. Two years waiting period
iii. Four years waiting period.
10. Thus Insurance Companies denying the benefit of the Insurance coverage obtained by their clients, when it comes to the question of settlement of Claims, at which time only the Insurance Companies come up with un-ethical & un-realistic concepts for their repudiating of the Claims. In the instant case, we are totally opposed to the contention of the OP in repudiating the Claim of the Complainant for reimbursement of expenses to the tune of Rs 4,41,289/-. Further the contention of the OP that purchase of the latest policy on 26.02.2016 is treated as new Policy and there is a break in the continuity of the policy and hence the Complainant cannot be given the benefit of waiving the pre-existing disease. Thus OP come up with such a contention, when both the parties are known to each other for over 4 years by way of serving a Mediclaim Policy and that the Complainant was also known to be suffering from Coronary Artery disease and further a new Policy was issued after the previous Policy was not renewed immediately on its expiry of its stipulated term and not examined the Complainant before issuing the policy. In the circumstances, the act of OP in not reimbursing the hospital charges to the complainant, amounts to deficiency in service and accordingly, proceed to allow the Appeal. Consequently, impugned Order dated 23.04.2018 passed in Consumer Complaint No.46/2017 on the file of I Additional District Consumer Disputes Redressal Forum, Bangalore is hereby set aside and directing the OP, if the claimed amount is backed up by appropriate documentary support, to pay a sum of Rs.4,41,289/- to the Complainant from the Date of Claim preferred, till its settlement in full within 3 months from the date of receipt of the order.
11. Send a copy of this Order to the District Commission, as well as to the parties concerned, immediately.
Lady Member Judicial Member President
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