The direction of the commission was in respect of two cases
‘Ectopic pregnancy is not a normal pregnancy and is a condition which needs surgery’
BANGALORE: In separate cases, the Karnataka State Consumer Disputes Redressal Commission directed the insurance companies involved to reimburse the medical expenses incurred by two women.
The commission directed the New India Assurance Co. Ltd., New Delhi, to pay Hanumantharayappa Rs. 30,000 with six per cent interest per annum and reimburse the expenses incurred for the treatment of his wife.
Mr. Hanumantharayappa, who works with Goetze (India) Ltd., has a medical policy that covers himself and his family.
His wife Bhagyalakshmi, who suffered from abdominal pain, was brought for a check-up to K.K. Hospital. Tests showed she was pregnant.
When she continued to suffer severe pains, she was taken to Bhagawan Mahaveer Hospital where she underwent surgery for ectopic pregnancy.
Mr. Hanumantharayappa made a claim for Rs. 30,000, the amount spent on the treatment.
The insurance company refused to pay up saying the policy excluded the third pregnancy.
He filed a complaint before the District Consumer Disputes Redressal Forum, which dismissed it.
Allowing the appeal, the State Commission noted that ectopic pregnancy was not a normal pregnancy and was a condition which required immediate surgery. There was no reason to repudiate the claim, it said.
In another case, the Commission directed Bajaj Allianz General Insurance to pay Rs. 17.17 lakh to Valsa Jose for the expenses she incurred in getting treatment for her heart problem in the United States.
Ms. Jose and her husband obtained an overseas travel insurance policy before leaving for Woodbury, MN, to see their daughter.
There she fell ill and doctors at St. Joseph’s Hospital performed an angiogram and angioplasty of right coronary artery, which cost her $36,538.47.
The insurance company rejected her claim for Rs. 17.17 lakh on the ground that she had not disclosed that she was hypertensive.
She termed the repudiation illegal and filed a complaint before the Commission.
Allowing the complaint, the commission noted that the repudiation was purely based on the investigation report.
The insurance company has not filed affidavit of the person who investigated the matter.
“In absence of such evidence no reliance could be placed on the said report, since the very contents of the report have not been proved or established by examining the investigator.”
The insurance company has failed to establish the suppression of facts, the commission noted.