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KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION
K. Ramanna, President, A.M. Bennur and Rama Ananth, Members
NEW INDIA ASSURANCE CO. LTD. - Appellant
Versus
S. RAJA AND ORS. - Respondents
Appeal No. 2176 of 2010
Decided on : 29-03-2011
Mr. C.R. Ravishankar, Advocate, for the Appellant; Mr. A.C. Chetan, Advocate, for the Respondent
Interpretation of insurance policy clauses and burden of proof in establishing pre-existing conditions.
Headnote:
Insurance Policy - Medical Expenses Reimbursement - Clause 4.3 - Venous Thrombosis, Pulmonary Embolism - [Insurance Policy] - [Clause 4.3] - The court discussed the terms and conditions of the insurance policy, specifically focusing on Clause 4.3, which excluded coverage for certain ailments. The court interpreted the clause in light of the complainant's medical condition, emphasizing that the ailment suffered was not excluded under the policy. This interpretation influenced the court's decision to confirm the order for medical expenses reimbursement.
Fact of the Case:
The complainant, an employee of Bharat Electronics Officers Club, underwent medical treatment covered by a Swastik Health Care Medical Policy. The insurance company and third party administrator rejected the claim, leading to a complaint before the DF.
Finding of the Court:
The court found that the medical treatment received was not excluded under the insurance policy, and the insurance company failed to prove the complainant's alleged suppression of pre-existing disease. Therefore, the court confirmed the order for medical expenses reimbursement.
Issues: Dispute over reimbursement of medical expenses under the insurance policy, alleged suppression of pre-existing disease by the complainant.
Ratio Decidendi: The court's decision was based on the interpretation of Clause 4.3 of the insurance policy, which excluded coverage for certain ailments. The court found that the complainant's ailment was not excluded under the policy and the insurance company failed to prove suppression of pre-existing disease.
Final Decision: The appeal was dismissed, and the order for medical expenses reimbursement was confirmed.
ORDER
K. Ramanna, President - This is an appeal filed by OP No. 2 challenging the order dated 4.5.2010 passed by the IV Addl. DF, Bangalore in Complaint No. 796/2009 whereby the complaint filed by the complainant came to be allowed directing OP Nos. 2 and 3 jointly and severally to reimburse Rs. 1,00,000 towards medical expenses of the complainant with interest at 9% p.a. from the date of this complaint along with litigation expenses of Rs. 2,000 to the complainant. Hence, this appeal.
2. The facts of the case are as follows:
Complainant is an employee of Bharat Electronics Officers Club. The said club has taken Swastik Health Care Medical Policy from OP No. 2/Insurance Company to its employees. The said policy was valid from 28.11.2007 to 27.11.2008 for Rs. 1,00,000 each. On 28.6.2008 the complainant admitted to Bhagvan Mahaveer Jain Heart Centre and due to chest pain and undergone surgery for deep venous thrombosis of legs, pulmonary embolism and IVC filter and discharged on 12.7.2008 by spending Rs. 1,24,954 towards medical expenditure. Thereafter he submitted claim to the OPs. OPs repudiated the claim. Therefore, he filed a complaint before the DF.
3. On service of notice, OPs 1 to 3 appeared through its Counsel filed its version denying the averments of the complaint contending that OP No. l is only a corporate agent of OP No. 2, Insurance Company and its duty is to collect premiums from the customers and pay the premiums to the Insurance Company by deducting commission. In turn OP No. 2 issued policy to the insured. OP No. 2 contending that the complaint is not maintainable and within one year from the date of obtaining the policy the insured is not entitled for reimbursement of treatment expenses for the decade arising within one year and denied about the ailment and expenditure incurred by the complainant under Clause 4.3 of the Insurance Policy terms and conditions. OP No. 3 contended that he is third party administrator acting on behalf of Insurance Company/OP No. 2 and within 7 months of the policy he had taken treatment for his ailment and the said treatment is not covered under Clause 4.3 of the policy terms and conditions. Hence, prayed for dismissal of the complaint.
4. In order to substantiate the complainant averments, complainant filed the affidavit evidence and produced some documents. OPs have also filed affidavit evidence and produced some documents.
5. After hearing the arguments, the DF was pleased to allow the said complaint vide its order dated 4.5.2010. Being aggrieved by the said order, now the OPs have come up with this appeal.
6. We have heard the arguments of the learned Counsel for the appellant and respondent.
7. In view of the above said facts, the point that arises for our consideration is:
1. Whether the impugned order under appeal is erroneous, unjust and improper
2. If so, whether it calls for interference from this Commission
3. What order
8. We have gone through the pleadings of the parties both oral and documentary evidence, the impugned order under appeal, grounds urged in the appeal memo and the arguments advanced.
Point No. l:
9. It is not in dispute that Complainant is an employee of Bharat Electronics Officers Club. The said club has taken Swastik Health Care Medical Policy from OP No. 2/Insurance Company to its employees. The said policy was valid from 28.11.2007 to 27.11.2008 for Rs. 1,00,000 each. On 28.6.2008 the complainant admitted to Bhagvan Mahaveer Jain Heart Centre and undergone surgery for deep venous thrombosis of legs, pulmonary embolism and IVC filter and discharged on 12.7.2008 by spending Rs. 1,24,954 towards medical expenses. According to the respondent No. l/complainant, OP No. l/Respondent No. 2 being an agent has collected premium and sent the same to appellant/OP No. 2 for issuance of the medi claim policy. OP No. 2 is the Insurance Company. OP No. 3 who is a third party administrator acting on behalf of Insurance Company/OP No. 2. The decision taken by appellant/OP No.2 h
