Karnataka High Court
National Insurance Co., Ltd., vs Mrs. Shivaprabha Jayaprakash Shetty on 19 February, 2020
Author: Ravi Malimath
Bench: Ravi Malimath
1
IN THE HIGH COURT OF KARNATAKA AT BENGALURU
ON THE 19TH DAY OF FEBRUARY, 2020
BEFORE
THE HON'BLE MR. JUSTICE RAVI MALIMATH
AND
THE HON'BLE MR. JUSTICE M.I.ARUN
WRIT APPEAL No.3944 OF 2019 (GM-RES)
BETWEEN:
NATIONAL INSURANCE CO., LTD.,
NO.3, MIDDLETON STREET
PRAFULLA CHANDRA SEN SARANI
KOLKOTTA - 700 071
REPRESENTED BY GENERAL MANAGER
THROUGH ITS REGIONAL OFFICE NO.144
SUBHARAM COMPLEX
M G ROAD, BENGALURU - 560 001
IN THIS APPEAL NOW
REPRESENTED BY ITS REGIONAL MANAGER
... APPELLANT
(BY SRI. B.C. SEETHA RAMA RAO, ADVOCATE)
AND:
1. MRS. SHIVAPRABHA JAYAPRAKASH SHETTY
AGED ABOUT 54 YEARS
WIFE OF LATE JAYAPRAKASH SHETTY
RESIDING AT NO.401-C, MAHAVEER JONQUIL
3RD FLOOR, VIVEKANANDA COLONY
J.P.NAGAR, 7TH PHASE, PUTTENAHALLI
BENGALURU - 560 078
2
2. UNION OF INDIA
DEPARTMENT OF FINANCIAL SERVICES
JEEVAN DEEP BUILDING
III FLOOR, SANSAD MARG
NEW DELHI - 110 001
REPRESENTED BY ITS SECRETARY
3. VIPUL MED CORP TPA PVT., LTD.,
NO.110, 4TH FLOOR, K.H. JROAD
SUDHAMANAGAR
BENGALURU - 560 0027
REPRESENTED BY ITS DIRECTOR
4. OFFICE OF THE INSURANCE
OMBUDSMAN (KARNATAKA)
NO.19/19, JEEVAN SOUDHA BUILDING
GROUND FLOOR, 24TH MAIN
J.P. NAGAR I PHASE
BENGALURU - 560 078
REPRESENTED BY ITS SECRETARY
... RESPONDENTS
(BY SMT. MONICA PATIL, ADVOCATE FOR R1
SRI. B.S. PRAMOD, CGC FOR R2)
THIS WRIT APPEAL IS FILED UNDER SECTION 4
OF THE KARNATAKA HIGH COURT ACT PRAYING TO
SET ASIDE THE ORDER DATED 20.08.2019 MADE IN
WP.NO.52434/2018 (GM-RES) BY THE LEARNED
SINGLE JUDGE OF THIS HON'BLE COURT AND TO
DISMISS THE WRIT PETITION FILED BY THE FIRST
RESPONDENT.
THIS WRIT APPEAL HAVING BEEN HEARD AND
RESERVED ON 29.01.2020 FOR JUDGMENT AND
COMING ON FOR PRONOUNCEMENT OF JUDGMENT
THIS DAY, M.I.ARUN J., DELIVERED THE FOLLOWING:
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JUDGMENT
Aggrieved by the order dated 20.08.2019 passed in Writ Petition No.52434 of 2018 by the learned Single Judge in allowing the writ petition, the respondent No.2 therein, is in appeal.
2. The brief facts of the case are that the respondent No.1 along with her late husband and daughter had secured a policy from the appellant herein for a period from 29.03.2013 to 28.03.2014 under which her family was insured with regard to hospitalization expenses for an amount of Rs.2,00,000/- each. The 1st respondent's late husband thereafter got the family insured under National Mediclaim Policy under which the 1st respondent's family was given the health insurance for an amount of Rs.2,00,000/- each for a period from 29.03.2014 till 28.03.2015. The 1st respondent's late husband was hospitalized for a period from 01.04.2014 to 02.04.2014 and 4 thereafter from 09.04.2014 till 09.07.2014. He was diagnosed with cysticero meningitis with artheritis. Again he was hospitalized from 24.07.2014 to 06.08.2014. The National Mediclaim policy was renewed. Again he was intermittently hospitalized. The husband of appellant No.1 sought to enhance the sum insured. The appellant was well aware of the medical history of the patient, suggested a new policy namely National Parivar Mediclaim Plus for the period from 29.03.2016 to 28.03.2017. He availed the said policy. Accordingly, the sum insured was Rs.15,00,000/-. The said policy was renewed for a further period of one year from 29.03.2017 to 28.03.2018. The husband of respondent No.1 was admitted to Apollo hospital on 04.10.2017. When so admitted, at the request of respondent No.1, respondent No.3 herein communicated to the hospital on behalf of the appellant herein that there is an approval for an amount of Rs.3,60,000/- to be 5 paid to the hospital by the insurance company, which was the initial estimated expense. Unfortunately, the husband of respondent No.1 expired on 30.10.2017. The total hospital expenses came to Rs.14,65,999/-. The respondent No.1 on 02.11.2017, filed a claim of reimbursement of expenses incurred on the hospitalization of her husband. The aforesaid claim was rejected on 20.02.2017 by the appellant on the ground that the petitioner was not entitled to reimbursement beyond a sum of Rs.2,00,000/-. Aggrieved by the same, the respondent No.1 thereupon, approached respondent No.4 namely the ombudsman, who by an award dated 28.09.2018, partly allowed the claim of the respondent No.1 by awarding a sum of Rs.3,60,000/- equivalent to what was initially approved by the respondent No.3 herein on behalf of the appellant herein and held that the respondent 6 No.1 is not entitled to a sum of Rs.14,65,999/- as claimed by her.
3. Challenging the same, respondent No.1 preferred Writ Petition No.52434 of 2018. In the writ petition, the learned Single Judge concluded that the husband of petitioner has not died on account of pre-existing disease before availing the insurance policy. He has been its customer for a few years and the appellant herein was fully aware about the health condition of the husband of respondent No.1 and has renewed the National Parivar Mediclaim Plus Insurance policy under which, the money is sought to be released. On these grounds, the writ petition was allowed and the appellant herein has been directed to reimburse a sum of Rs.14,65,999/-.
4. We do not find any reason to interfere with the order of the learned Single Judge. Based on the records, it is noticed that the husband of respondent 7 No.1 was suffering from chronic meningitis with arteritits before availing the National Parivar Mediclaim Plus insurance policy. Nevertheless, when the husband of respondent No.1 availed of the said policy in the year 2016, the insurance company was aware of it as he was their customer with another policy prior to it. But, it is as per the letter issued by one Dr.Vikram V. Kamath, who is supposed to have trated the husband of respondent No.1, as per Annexure - U to the writ petition, the husband of respondent No.1 was admitted to the hospital on 04.10.2017 with acute fever/breathing difficulty and hypotension. He was diagnosed with left lung pneumonia and effusion and sepsis and that he expired due to florid sepsis. He was earlier treated for meningitis with arteritits and his current problem was not related to the same. It also clarifies that his past condition is unrelated to the present cause of death. The said letter has not been disputed by the 8 appellant nor has been considered by the appellant or respondent No.4 - Ombudsman. They have relied upon the death summary issued by Apollo hospital produced at Annexure - V to the writ petition. That under the column cause of death, the disease mentioned is 'Past chronic meningitis with arteritits' along with several other diseases. The same has been clarified in the letter of the said Dr.Vikram B. Kamath at Annexure - U, which indicates that the discharge summary will always contain present and past diagnosis and his past condition is unrelated to present cause of death. The only ground on which compensation has been denied to him by respondent No.4 and the appellant herein is that the cause of death was past chronic meningitis with arteritits. It was a pre-existing disease prior to availing National Parivar Mediclaim Plus Insurance Policy and that 36 months has not lapsed since availing of the same. The appellant has challenged the order of the 9 learned Single Judge only on this ground. Reading of the letter issued by the concerned doctor and the death summary report of Apollo hospital shows that the husband of the petitioner got admitted and treated for disease other than chronic meningitis with arteritits and his death was also because of other reasons. The same has not been considered and ignored by the appellant and respondent No.4 herein.
5. Under these circumstances, we do not find any reasons to interfere with the order of the learned Single Judge and the writ appeal is hereby dismissed.
Sd/-
JUDGE Sd/-
JUDGE MH/-