State Consumer Disputes Redressal Commission
Sri. Prakash Kulkarni vs The Manager & Others on 2 November, 2011
BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE. DATED: 02/11/2011 PRESENT THE HONBLE MR.JUSTICE K.RAMANNA : PRESIDENT SRI.A.M. BENNUR : MEMBER SMT.RAMA ANANTH : MEMBER Appeal No. 97/2011 Sri. Prakash Kulkarni S/o. Kishnarao, Aged 51 years, Occ : Tax Consultant, R/o.H.No.8-9-356, Bhagwati Nivas, Devi Colony, Bidar. (By Shri/Smt Smt. Saritha Kulkarni) . Complainant before the DF .....Appellant/s -Versus- 1. The Manager Bajaj Allianz Life Insurance Co. Ltd., GE Plaza, Airport Road, Yerwada, Pune 411 006. 2. The Manager, Bajaj Allianz Life Insurance Co. Ltd., Mahagaonkar, No.1-18/A, 2nd Floor, Court Road, Behind KEB Office, Gulbarga. 3. The Manager, Bajaj Allianz Life Insurance Co. Ltd., Rishikesh Complex, Udgir Road, Bidar 585 401. (By Shri/Smt Geeta Raj) .. Opposite Party before the DF .....Respondent/s O R D E R
HONBLE JUSTICE MR.K. RAMANNA : PRESIDENT This appeal is filed under Section 15 of the C.P Act by the unsuccessful complainant to set aside the order dated 02.12.2010 passed by the DF, Bidar in Complaint No. 63/2010 whereby his complaint came to be dismissed.
Therefore, he has come up with this appeal mainly on the ground that, though the DF admitted the fact that the appellant was detected from cancer after one year, but very strangely comes to the conclusion that cancer was detected within 15 days from the date of renewal of the policy. When once the DF having come to the conclusion that, appellant has renewed the policy within the grace period of 15 days as stipulated under clause 11, but erred in holding violation of 7(b) (i)
(ii) of the policy and it misunderstood the meaning of the word renewal and revival as same. Therefore, prays for to set aside the order and to allow his complaint.
2. After service of notice, respondent appeared through counsel and resisted the appeal contending that, the DF is right in dismissing the complaint. The policy has been obtained by suppressing the pre-existing disease Cancer. He has undergone treatment for the cancer immediately after the revival of the health care policy. Therefore, appeal is liable to be dismissed.
3. We have heard the arguments of learned counsel for both the sides and perused the records.
4. In view of the above said facts, the point that arises for our consideration is:
1. Whether the order under challenge is perverse and incorrect?
2.
If so, what order?
5. Point No.1:- Of course the appellant herein who had taken a policy introduced by the respondent/OP under Bajaj Allianz Family Care First by submitting his proposal. At the time of issuance of the policy, he was aged about 48 years. Policy was in force in between 15.11.2008 to 15.11.2011 that is three years policy. Annual premium fixed was Rs. 8,386/-. But the appellant has not renewed the said policy well in advance in the second year.
But it was renewed on 30.11.2009 within the grace period of 15 days by paying a sum of Rs. 7,251/-/. The appellant developed health problem like belching and Dyspepsia, history of weight loss and appetite. He got admitted in the Asian Institute of Gastroenterology, Hyderabad on 08.12.2009 and undergone surgery on 14.12.2009 and finally discharged on 26.12.2009. According to him, he had paid in all Rs. 1,59,675/- towards medical expenses. It is argued by the learned counsel for the appellant that, the DF has not properly understood the word renewal and revival and come to the erroneous conclusion in dismissing the complaint.
6. On the other hand, the learned counsel for the respondent argued that the policy has been obtained by suppressing the pre-existing disease and he has not renewed the policy in time and renewed on 30.11.2009 only.
Therefore, the DF is right in dismissing the complaint.
7. In order to appreciate the contention of both the parties, it is just and proper to cull out the Condition No. 7 (b) (i) and (ii).
The DF said to have been gone through the meaning of renewal and revival in Oxford Dictionary. Of course the renewal date being a subsequent event, but it was detected within 15 days from the date of renewal of the policy. Under the head waiting period, Condition No. 7 reads as follows;
Waiting period: 7: The Company shall not be liable to make any payment during the currency of the policy if claims are made due to;
a)
b) Any of the following illness if diagnosed or hospitalization or medical expenses incurred due to the first history days of the policy commencement date or date of revival whichever is later:
i) Tonsillectomy,
ii) Cancer of any kind.
8. There is no doubt that the appellant has undergone treatment for his cancer. The policy was renewed after one year by availing the grace period. The appellant/complainant violated the terms and conditions of the policy. The claim made by the appellant is against the terms and conditions of clause 7(b)(i)(ii) of the policy. Therefore the DF is right in coming to the conclusion that the complainant fails to prove the deficiency of service on the part of respondent/OP.
9. The medical certificate issued by the Asian Institute of Gastroenterology dated 15.12.2010 reads that;
Mr. Prakash Kulkarni was admitted in the said hospital on 14.12.2009 and he was diagnosed to have Carcinoma Esophagus + Positive for Malignancy. Moderately differentiated squamous cell carcinoma of esophagus.
10. The appellant herein has not produced the admission and discharge summary to show that what was the history furnished by him before the Hospital. As per the terms and conditions of the policy, renewal means, policy will automatically terminate at the expiry date. The company is not bound to give notice to the policyholder that it is due for renewal, or to renew it. It can be renewed within 30 days after the expiry date of the previous policy at the premium rates (if any) and the terms and conditions prevailing at the time of renewal of the policy. But immediately after the renewal of the policy i.e., on 30.11.2009, he was admitted to the Hospital on 08.12.2009 and detected the cancer by the Hospital Authorities.
11. The powers conferred on the Appellate Authority is to re-appreciate the evidence and the materials placed on record. The appellant/complainant obtained the policy in the year 2008, but renewed the policy by availing a grace period within 14 days and he has admitted to the Hospital on 08.12.2009 and undergone surgery on 14.12.2009. Therefore, in our opinion, the DF is right in dismissing the complaint by interpreting clause 7(b)(i)(ii) of the policy. In the instant case, the appellant herein who had taken family health care policy for a period of three years by paying first premium to cover the first year and there was a delay in renewing the said policy. But within the grace period of 15 days the policy was renewed and the disease for which he has undergone treatment was detected after the renewal of the policy i.e., on 08.12.2009. The parties are bound by the terms and conditions of the policy and therefore, even if he has undergone treatment for the said disease after renewal or revival, the company is not liable to pay any compensation.
Therefore, we are of the opinion that, the DF has rightly dismissed the complaint. Hence, appeal is liable to be dismissed. Accordingly, we pass the following:
O R D E R Appeal is dismissed. No order as to costs.
PRESIDENT MEMBER MEMBER Rhr**