IMPORTANT POINTS
(1) Significance of Policy Documentation – Policy documents issued by the appellant contained a “dash” in the column for pre-existing diseases. This serves as an admission by the insurer that no such diseases were declared or known at the time of issuance, making a subsequent defense of a “pre-existing ailment” legally unsustainable.
(2) Burden of Proof on the Insurer – Burden of proving that an insured suffered from a “pre-existing disease” rests solely on the insurance company. Mere allegations or unsubstantiated claims are insufficient to repudiate a claim. In this case, the appellant failed to produce any medical evidence to establish that the respondent’s heart condition existed prior to the policy inception.

JUDGMENT

Milind S. Sonawane, Presiding Member.—This is an appeal challenging correctness and legality of the judgment and order passed by the learned District Consumer Disputes Redressal Commission, Ahmadnagar (the ‘District Commission’ for short) in C.C. No. 204/2015, whereby the District Commission allowed the complaint filed by the respondents directing the appellant to pay to them sum of Rs.4,57,755/- towards the insurance claim along with Rs.20,000/- for the mental and physical harassment and Rs.5,000/- as the costs of the proceedings.

2. The brief facts of the appeal are that, the respondents in 2005 took the medi-claim policy from the appellant. It was renewed over the number of years till 2013. On 31.07.2013, the son of respondent no.2 i.e. respondent no.1 upgraded the policy by taking ‘family floater basic cover’ of Rs.7 Lakh and personal accident cover of Rs.35 Lakh under the ‘gold plan’. In this manner the entire family of the respondents was covered under the policy. When the policy cover was available from 31.07.2014 to 30.07.2015, respondent no.2 was admitted on 19.01.2015, firstly in Noble Hospital, Ahmadnagar. He was diagnosed to have heart attack. He was admitted in that hospital till 25.01.2015. He incurred expenses of Rs.62,588/-. Thereafter, he was admitted from 25.01.2015 to 05.02.2015 in Rubby Hall Clinic, Pune for the bypass surgery. There he incurred expenses of sum of Rs.4,74,264/-. Thereafter also for the same reason, he was admitted again in Nobel Hospital, Ahmadnagar from 07.02.2015 to 10.02.2015. He incurred sum of Rs.20,633/- on the post operative treatment. As such, in total, respondent no.2 has incurred Rs.5,57,755/- on medical treatment.

3. The respondents lodged the insurance claim for the above treatment with the appellant. The appellants however just paid Rs.1 Lakh for the insurance claim and on 22.04.2015 issued a letter stating that, the balance claim is repudiated, as the insured person has exhausted his applicable sum insured for the year. Against that repudiation the respondents filed the above mentioned Consumer Complaint before the District Commission, in which the impugned judgment is passed.

4. The appellant appeared before the District Commission and resisted the case filed by the respondents. It was contended that, since the sum insured for initially issued policy to respondent was Rs.1 Lakh and that subsequently in 2013 that policy was upgraded and enhanced to the insured sum of Rs.7 Lakh and that, the disease for which respondent no.2 was treated and operated in 2015, is for the pre-existing ailment, which was not covered for four continuous years as per the policy term clause No.4.1 and 4.3. The repudiation is valid. There is no deficiency in service caused to the respondents. They prayed that, the complaint filed by the respondents may kindly be dismissed with costs.

5. The District Commission on evaluating the evidence before it and on hearing the learned Counsels of both sides drawn the conclusion that, the appellant has not adduced any evidence to prove that, the heart disease for which respondent no.2 was treated and operated was ‘pre-existing’. It is therefore, clause no. 4.1 and 4.3 of the policy terms which mandates that, four continuous years must have elapsed for getting the insurance claim for that treatment. Thus, the District Commission directed the appellant to pay to the respondents balance amount of the insurance claim lodged by the respondents along with other reliefs.

6. We heard both learned Adv. J.K. Narayane for the appellant and Adv. P.P. Kothari for respondent no.1 and 2. On 9.9.2021 Adv. J.K. Narayane for the appellant filed a pursis that, appellant is not claiming any relief against respondent no.3, which is the formal party. Therefore, the matter proceeded further for the final hearing in the absence of respondent no.3.

7. At the outset it needs to be mentioned here that, there is no dispute between the parties as to the facts that the respondents took