Back
DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Sangita Dhingra Sehgal (President), Pinki, Member (Judicial) and J.P. Agrawal, Member (General)
Birla Sun Life Insurance
Company Ltd. and Ors. – Appellants
versus
Harish Grover – Respondent
First Appeal No.1102 of 2014
Decided on 24.3.2023
Consumer Protection Act, 1986 – S.15[Consumer Protection Act, 2019 – S.41] – Services – Insurance – medical – pre-existing illness – patient not suffering at the time of issuance of policy – No proof that patient had medical history - From the aforesaid settled law, it is clear that the common lifestyle disease like diabetes and hypertension, cannot be treated as pre-existing diseases, therefore, cannot be a ground of repudiation of the claim by Insurance companies - Further, it is well settled law that the Insurance company before issuing the policy should have examined the person through medical tests in order to check whether the person is suffering from any pre-existing diseases. In present case, the Appellants also examined the Respondent while obtaining both policies and he was declared as healthy. More so, it is clear that the Respondent did not have diabetes from the Appellant’s examination at the time of obtaining said policies, which revealed that the Respondent’s fasting blood sugar level was 76, within the normal range of 70 to 110 (Information annexed at page 40 of the present appeal). The Appellants further asserted that the Respondent also had history of asthma but no evidence has been placed by them to substantiate the same – Therefore, Appellants are deficient in providing services to the Respondent by declaring said policies of the Respondent as null and void in the guise of non-disclosure of pre-existing disease – Appeal dismissed. [Paras 10 to 12].
Result: Appeal dismissed.
Based on the provided legal document, the key points are as follows:
The case involves a dispute over the validity of life insurance policies issued to the Respondent, with the Appellants claiming that the policies should be declared null and void due to non-disclosure of pre-existing diseases, specifically diabetes mellitus and a history of asthma (!) (!) .
The District Consumer Disputes Redressal Forum found that the Respondent was examined at the time of policy issuance and was declared healthy, with medical reports indicating normal blood sugar levels and no evidence of diabetes or other illnesses at that time (!) (!) .
The Forum emphasized that common lifestyle diseases such as diabetes and hypertension are not to be considered pre-existing diseases unless there is evidence of hospitalization or treatment in the recent past or near the policy issuance date. Merely having a history of such conditions without recent treatment or hospitalization does not constitute concealment (!) (!) (!) (!) (!) .
The insurance company has an obligation to conduct medical examinations before issuing policies to identify pre-existing conditions. In this case, the Respondent was examined and declared healthy, and no medical evidence was produced by the Appellants to substantiate the concealment of any disease (!) (!) .
The legal principles clarify that unless an insured person is hospitalized or operated upon for a disease in the near proximity of policy issuance, such a disease cannot be deemed pre-existing. The concealment of hospitalization or treatment for a disease in this period is the key factor for repudiation of a claim (!) (!) (!) .
The Appellants failed to prove that the Respondent was suffering from diabetes or asthma at the time of obtaining the policies. The blood sugar levels at the time of examination were within normal limits, and no evidence of recent hospitalization or treatment was provided to establish concealment (!) (!) (!) .
The legal position holds that lifestyle diseases like diabetes and hypertension, which are common and controllable, are not to be treated as pre-existing diseases unless there is evidence of recent hospitalization or treatment for such conditions (!) (!) (!) (!) .
The conclusion of the appellate authority is that the Appellants were deficient in providing services by declaring the policies null and void on the grounds of non-disclosure, which was not supported by sufficient evidence. The original judgment of the District Forum was upheld, and the appeal was dismissed (!) .
The Respondent is entitled to the benefits of the policies, and the Appellants are directed to restore the policies along with full benefits, including compensation for mental pain and harassment, as well as costs of litigation (!) .
The overall legal stance underscores the importance of good faith, proper medical examination, and the limited scope of non-disclosure as a ground for repudiation, especially when the insured was not suffering from the disease at the time of policy issuance and there is no recent hospitalization or treatment evidence.
JUDGMENT
Sangita Dhingra Sehgal (President)—The facts of the case as per the District Commission record are:—
“This complaint has been filed with the allegation that the complainant has availed two policies in his name vide Policy No.003671118 and a premium of Rs.1,20,000/- was to be paid annually. The policy was valid from 28.12.2009 and the total sum assured was Rs.25,00,000/-. Second policy No.003867803 on the premium of Rs.1,20,166/- which was valid from 12.3.2010 and sum insured was Rs.6,00,000/- His health check-up was conducted on 16.12.2009 and medical examination report was also submitted. The complainant has paid so far Rs.3,60,000/- in respect of the premium of both policies. A new insurance policy in the year 2011 vide application no. A-42365683 dated 27.7.2011 was applied for and he was put to medical examination on 9.9.2011. The respondent intimated the complainant that they have cancelled the previous policies with immediate effect. The ground taken was non-disclosure of material facts regarding the diabetes mellitus. It amount to breach of trust. The respondent issued a cheque dated 23.9.2012 for an amount of Rs.1,41,907.75/- bearing no.191099 towards the policy no.003671118 and no amount has been refunded in respect of policy no.003867803. The respondent had issued both these policies after conducting the medical examination. The cancellation is arbitrary and amounts to unfair trade practices and deficiency in service. The complainant has prayed for the restoration of the two policies and compensation of Rs.4,00,000/- with cost of Rs.25,000/-.”
2. The District Commission after taking into consideration the material available on record passed the order dated 01.09.2014, whereby it held as under:—
“There is no dispute regarding this fact that policy no. 003671118 and policy no.003867803 were not issued by the respondent in the years 2009 and 2010. The complainant has come up with the specific allegation that at the time of buying the two policies, he was subjected to medical examination by the empanelled doctor of the respondent. The medical examination report dated 16.12.2209 submitted by the doctor to the insurance company confirms the allegation that he was subjected to medical test. It has been contended by the Ld. Counsel of the complainant that it was the duty of the respondent and their doctor Dr. Sandeep Singal who had conducted the medical test necessary to tule out any ailment to the complainant so as to found him fit for the issuance of the policy of insurance. The complainant has filed health check report showing the state of fasting blood sugar at 76, of which the normal range value is 70 to 110. This report shows that he was not having any diabetic problem, his blood sugar level was perfectly in odrder. His electro cardio gram also normal. The respondents have failed to file on record any report submitted by their medical examiner team regarding the ailments complainant was suffering and the report which they have considered to cancel the policies of the complainant. It was incumbent upon the respondent to have placed on record all the medical reports showing that at the time of issuance of the policies he was suffering from Diabetes mellitus. If the complainant was suffering from disease which could have disentitled him from the benefits of insurance, the same should be proved by the respondent. No such documents have been filed from the side of the respondent. On the contrary, the report filed by the complainant regarding the medical examination and health check blood test report, electro cardio gram, etc. reveal that his sugar level was perfectly normal. He was not suffering from diabetes mellitus or any other disease. In the absence of any proof of illness, the cancellation made by the respondent cannot be said to be justified. The cancellation made is contrary to selection 45 of the insurance act. The amount deducted at the time of the cancellation is also arbitrary and just. The total act
SupremeToday
Proof - The Appellants further asserted that the Respondent also had history of asthma but no evidence has been placed by them to substantiate the same.
Medical Examination – Insurance company is responsible for conducting a medical examination of the policyholder in advance.
(1) Proof of delivery - In the absence of proof of delivery, therefore, Commission cannot rely solely on the Respondent’s statement before the District Commission that it had duly supplied the terms ....
An insurer cannot repudiate a claim based on pre-existing conditions if the policy was issued following a medical examination. Furthermore, an insurer is precluded from relying on policy exclusion cl....
Since medical insurance policy was issued after examination of insured, policy claim cannot be repudiated on ground of pre-existing disease.
An indispensable Tool for Legal Professionals, Endorsed by Various High Court and Judicial Officers
Please visit our Training & Support
Center or Contact Us for assistance
Scan Me!
India’s Legal research and Law Firm App, Download now!
For Daily Legal Updates, Join us on :
Back to top
