State Consumer Disputes Redressal Commission
The Authorized Signatory vs Smt.V.S.Sharada on 8 March, 2022
Cause Title/Judgement-Entry KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION BASAVA BHAVAN, BANGALORE. First Appeal No. A/1412/2017 ( Date of Filing : 28 Jun 2017 ) (Arisen out of Order Dated 17/05/2017 in Case No. CC/1806/2017 of District Bangalore 3rd Additional) 1. The Authorized Signatory M/s Star Health and Allied Insurance Company Ltd., KRM Centre, 6th floor, No.2, Harrington road Chetpet, Chennai-600031. Through its Zonal office Esteem Tower, No.71, 3rd floor, Railway Parallel road, Kumara park west, Bangalore-560001 Rep. by its Vice President Mr.John Noronha. ...........Appellant(s) Versus 1. Smt.V.S.Sharada W/o Muddudveeraiah, Aged about 56 years, R/a No.100, Akshaya Mahal, II main road, 2nd cross, K.K.Layout, Pappareddy palya, Nagarabhavi II stage, Bangalore-560072. 2. Mr.Mudduveeraiah Aged about 62 years, S/o Muddabasappa, R/a No.100, Akshaya Mahal, II Main road, 2nd cross, K.K.Layout, Pappareddy palya, Nagarabavi II stage, Bangalore-560072 ...........Respondent(s) BEFORE: HON'BLE MR. Ravishankar PRESIDING MEMBER HON'BLE MRS. Smt.Sunita Channabasappa Bagewadi MEMBER PRESENT: Dated : 08 Mar 2022 Final Order / Judgement BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE (ADDL. BENCH) DATED THIS THE 8th DAY OF MARCH 2022 PRESENT MR. RAVISHANKAR : JUDICIAL MEMBER MRS. SUNITA CHANNABASAPPA BAGEWADI : MEMBER APPEAL No. 1412/2017 The Authorized Signatory, M/s Star Health & Allied Insurance Company Ltd., KRM Centre, 6th Floor, No.2, Harrington Road, Chetpet, Chennai 600031, Through its Zonal Office, Esteem Tower, No.71, 3rd Floor, Railway Parallel Road, Kumara Park West, Bangalore 560 001, Rep. by its Vice President Mr. John Noronha. (By Sri S. Krishnakishore) ......Appellant/s V/s 1. Smt. V.S. Sharda, W/o Mudduveeraiah, Aged about 56 years, Residing at No.100, 'Akshaya Mahal', 2nd Main Road, 2nd Cross, K.K. Layout, Papareddy Palya, Nagarabhavi 2nd Stage, Bangalore 560072. ...Respondent/s 2. Sri Mudduveeraiah, Aged about 62 years, S/o Muddabasappa, Residing at No.100, 'Akshaya Mahal', 2nd Main Road, 2nd Cross, K.K. Layout, Papareddy Palya, Nagarabhavi 2nd Stage, Bangalore 560072. (By Smt. Jayanthi) ORDER
MRS. SUNITA CHANNABASAPPA BAGEWADI, MEMBER
1. The appellant/complainants have preferred this appeal being aggrieved by the Order dt.17.05.2017 passed in CC.No.1806/2015 on the file of 3rd Additional District Consumer Disputes Redressal Commission, Bangalore.
2. The brief facts of the complaint are hereunder;
It is the case of the complainants that the complainant No.2 took a policy from the Opposite Party under the product Medi Classic Individual, revised under policy No.P/141125/ 01/2015/007981 which was in force from 09.01.2014 to 08.01.2015 in favour of the complainant No.1. The complainant No.1 admitted to Unity Lifeline Hospital from 10.11.2014 to 13.11.2014 for abdominal incessional hernia and spent Rs.59,960/- including medicines for which the complainant No.2 seeks reimbursement of the expenses for the above treatment with the Opposite Party by producing all the relevant documents pertaining to the claim, but, the Opposite Party repudiated the claim on the ground that during the first and second year of the policy as per the exclusion clause No.3, the insured is not liable for any claim. Aggrieved by this, the complainants issued a legal notice to the Opposite Party to honour the claim for which the Opposite Party sent a reply notice on 09.03.2015. Hence, the complainant filed a complaint alleging deficiency in service on the part of the Opposite Party.
3. After service of notice, the Opposite Party appeared through counsel and admitted the policy in question. Further contended that the as per Exculsion Clause No.3 of the policy terms and conditions, the insurance company is not liable to make any payment in respect of any expense incurred by the insured for the abdominal hernia during first two years of continuous operation of the insurance cover. Hence, she is not eligible for making claim for medical expenses. Hence, there is no deficiency in service on the part of the Opposite Party and prayed dismiss the complaint.
4. After trial, the District Commission allowed the complaint and directed the Opposite Party to pay a sum of Rs.60,000/- with interest at 18% p.a. from 16.12.2014, till the date of payment along with Rs.10,000/- towards compensation and Rs.3,000/- towards costs.
5. Being aggrieved by the said Order, the appellant/ Opposite Parties are in appeal. Heard both sides.
6. Perused the appeal memo, impugned Order passed by the District Commission, we noticed that it is not in dispute that the Respondent No.2 has took medical insurance policy bearing No.P/141125/ 01/2015/007981 which was in force from 09.01.2014 to 08.01.2015. It is also not in dispute that the Respondent No.1 Smt. V.S. Sharda admitted to Unity Lifeline Hospital for abdominal incessional hernia from 10.11.2014 to 13.11.2014 and spent Rs.59,960/- including medicines. The Respondent No.2 submitted the claim form to the Opposite Party for reimbursement of the medical expenses, the appellant instead of settling the claim repudiated the claim on the ground that the Respondent No.1 insured person has undergone treatment for the above disease during the first year of the policy and as per Exclusion Clause No.3 of the policy, the appellant is not able to make any payment.
7. On perusal of the Order passed by the District Commission, we noticed that the Respondent No.1 was hospitalized and taken treatment for abdominal incessional hernia in Unity Lifeline Hospital and spent Rs.59,960/- including medicines from 10.11.2014 to 13.11.2014. We perused the policy and agreed that the policy was in force from 09.01.2014 to 08.01.2015 and Respondent No.2 filed a claim with the appellant with relevant documents. The Respondent No.1 underwent treatment for the first year obtaining the policy which is not covered for first two years from the date of taking the policy. However, as per the Exclusion Clause No.3 of the policy terms and conditions Clause No.3 During the first two years of continuous operation of insurance cover:
(a) The expenses for treatment of cataract, glaucoma, retinal detachment/ macular degeneration, prolapsed of intervertebral disc (other than caused by accident), varicose veins and varicose ulcers, benign prostatic hypertrophy, deviated nasal septum, sinusitis, tonsillitis, nasal polyps, chronic supparative otitis media and related disorders, stapedectomy, hernia, hydrocele, fistula/fissure in ano and hemorrhoids, congenital internal disease/defect.
Hence, the insurance policy terms and conditions are binding by both the parties and they should honour the same. Moreover, the District Commission gave findings that the complainant Nos. 1 & 2 are not the signatories to the policy, therefore, it is not proper to accept the contention taken by the Opposite Parties/appellants and the complainants are not party to the document and the documents has not executed by the complainants. Perused the policy, the policy number is same, date of issuance of the policy is same, policy holder name is same and the proposor name is also same and it is not the case of the complainant. Hence, it is not the duty of the commission below to discuss on such issues which is no raised by the complainant. Hence, in our opinion, the repudiation of the claim of the complainant is just and proper. Considering the facts and circumstances made here, we are of the opinion that the order passed by the District Commission is not in accordance with law. Hence, the following;
ORDER The appeal is allowed. Consequently, the complaint is dismissed.
The amount in deposit shall be refunded to the appellant.
Forward free copies to both parties.
Sd/- Sd/- MEMBER JUDICIAL MEMBER KCS* [HON'BLE MR. Ravishankar] PRESIDING MEMBER [HON'BLE MRS. Smt.Sunita Channabasappa Bagewadi] MEMBER