State Consumer Disputes Redressal Commission
Hdfc Ergo Ergo Health Insurance Co Ltd ... vs Sri Muralidhara M.N on 22 August, 2024
1 Appeal No.875/2023
Date of Filing : 18.05.2023
Date of Disposal : 22.08.2024
BEFORE THE KARNATAKA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION, BENGALURU (PRINCIPAL BENCH)
DATED THIS THE 22nd DAY OF AUGUST 2024
PRESENT
Mr. K.B.SANGANNANAVAR : JUDICIAL MEMBER
Mrs. M.DIVYASHREE : LADY MEMBER
APPEAL NO.875/2023
HDFC Ergo Health Insurance Co., Ltd.,
Formerly Apollo Munich Health Insurance Co., Ltd.,
Central Processing Centre,
2nd & 3rd floor, i LABS Centre,
Plot no.404-405, Udyog Vihar,
Phase-iii, Gurgaon-122016.
Rep. by its Legal Manager Legal Claims - South,
Bengaluru Regional Office
Gukanti Suresh. ..Appellant/s
(By Adv.Sri.Krishna Kishore)
Vs
Muralidhara.M.N
Aged about 66 years,
S/o late M.G.Narayana Rao,
iii Main Road, 4th phase,
7th block, BSK iii stage,
Bengaluru-85. ..Respondent/s
(By Adv.Sri.Velangani.C)
2 Appeal No.875/2023
ORDER
BY Mr.K.B.SANGANNANAVAR : Pri.Dist & Session Judge (R) - JUDICIAL MEMBER.
1. This is an appeal filed U/s.41 of CPA 2019 by OP/Appellant aggrieved by the order dtd.07.02.2023 passed in CC/523/2021 on the file of 1st Addl., Bengaluru District Commission.(Parties to the appeal henceforth are referred to their rank assigned to them by the District Commission).
2. The Commission examined the grounds of appeal, impugned order, appeal papers and heard the learned counsels.
3. Now the point that arise for consideration of this Commission would be:
Whether the impugned order dtd.07.02.2023 passed in CC/523/2021 does call for an interference of this Commission for the grounds set out in the appeal memo ?
4. Learned counsel for Appellant/OP submits, wife of the Complainant had suffered Ischemic Heart disease and mitral valve prolapsed in the year 2012 and she took treatment for the said ailment. On 13.09.2019, she had underwent ECHO Cardiograph test and she was diagnosed for mitral valve prolapse. She was admitted to Fortis hospital, Bannerghatta road on 04.01.2020 and discharged on 10.01.2020, wherein 3 Appeal No.875/2023 underwent surgery. It is not in dispute that Complainant had obtained policy from OP w.e.f 21.11.2017. According to OP/Appellant Complainant had concealed the material fact regarding ailment of IHD and mitral valve prolapsed to his wife in the year 2012, which was not properly appreciated by the District Commission. Learned counsel further submits that District Commission had failed to appreciate the defence taken up by the OP and failed to consider suppression of pre-existing diseases, such as mitral valve prolapsed to his wife/Smt.Rajalakshmi in the year 2012 was concealed by the insured.
5. The Commission had benefit to examine the Award No.IO/(BNG)/A/HI/0228/2020-21 of Ombudsman for State of Karnataka wherein observed "the documents and proposal form of IP submitted at the time of inception of policy period that: The discharge summary of Apollo hospital for the period 11.09.2012 to 11.09.2012 shows that IP was diagnosed with MVP with angina-normal coronaries, coronary angiogram dtd.11.09.2012 under clinical diagnosis shows IHD, mitral valve prolapsed. Medication on discharge shows that IP was advised with related medicines - to be continued and the Ombudsman held taking into account of the facts and circumstances of the case the documents 4 Appeal No.875/2023 and the oral submissions made by both the parties, does not find any flaw with the decision of the Respondent insurer in rejection of claim and cancellation of policy as above in accordance with the terms & conditions of the policy."
6. Let us examine the impugned order, wherein the District Commission in para 8 observed "Admittedly the policy was issued on 23.11.2019 and the validity of the said policy was from 26.11.2019 to 25.11.2020 and during the validity period of Group Health Insurance policy, Smt.Rajalakshmi W/o complainant was taken treatment with Fortis Hospital. It is not in dispute that, liability of insured under the policy is subject to terms & conditions and sum assured is Rs.12 lakhs. The OP/insurer had verified the claim form submitted by the Complainant along with documents for having spent Rs.7,77,965/- towards medical expenditure not only repudiated the claim and also cancelled the insurance policy for concealment of pre-existing diseases. It is to be noted herein District Commission held, wife of Complainant underwent only medical tests not for any surgery and the doctor prescribed medicine for the period of 15 days and after 15 days, she has to stop taking medicines and her health condition was good since from October 2012 till 23.09.2019. Learned counsel for 5 Appeal No.875/2023 Respondent/Complainant submits Smt.Rajalakshmi W/o Complainant for almost 7 years was keeping good health was rightly appreciated by the District Commission. It is not that first time Complainant had obtained the policy on 23.11.2019 and for a long gap of 8 years from 2012 she took treatment in Fortis hospital for which Complainant cannot be said had suppressed the pre-existing diseases such as mitral valve prolapsed in the year 2012, which in our view was rightly appreciated by the District Commission. In such view of the matter viewed from any angle Complainant/insured cannot be held had concealed pre-existing diseases of Smt.Rajalakshmi since her health condition from 2012 to the date of her taking treatment with Fortis hospital, Bengaluru found good even from medical records. Learned counsel for Respondent/Complainant submits pre-existing condition defined as per the policy documents "Pre-existing condition means any condition, ailment or injury or related condition/s for which insured person had signs or symptoms and or were diagnosed and or received medical advice/treatment within 48 months prior to your first policy with any insurer." Admittedly first policy was obtained during 2017 and the Complainant under group health insurance policy sought for reimbursement of medical 6 Appeal No.875/2023 expenditure of Smt.Rajalakshmi/his wife for her taking treatment with Fortis hospital on 04.01.2020 by then almost 4 years lapsed, it does mean 48 months were lost and in such circumstances, repudiation of claim submitted by the Complainant could be said unjust. In such view the District Commission has to be held rightly appreciated the materials on record and arrived at a right conclusion to direct insurer to pay Rs.7,88,143/- along with interest at 6% p.a. which does not call for any interference but awarding compensation of Rs.50,000/- towards mental agony has to be held on higher side is hereby reduced to Rs.10,000/-. Accordingly proceed to dispose of the appeal with no order as to cost.
7. The amount in deposit is directed to be transferred to the District Commission for needful.
8. Notify copy of this Order to the District Commission and parties.
Lady Member Judicial Member *NS*