AVM J. RAJENDRA, AVSM, VSM (RETD.), MEMBER

1.      The present First Appeal has been filed under Section 19 of the Consumer Protection Act, 1986 (hereinafter referred to as “the Act”) against the Order dated 22.01.2021 passed by the learned State Consumer Disputes Redressal Commission, Lucknow, U.P. (hereinafter to be referred as “the State Commission”), in Consumer Complaint No. 521 of 2017, wherein the Complaint filed by the Complainant (Respondents herein) was partly allowed.

2.      For the sake of Convenience, the parties in the present matter being referred to as mentioned in the Complaint before the State Commission. Mr. Atul Kumar & Anr. are identified as the Complainants. While "M/s. Star Health and Allied Insurance Co. Ltd. & Anr." are referred to as the Opposite Parties / Insurer (OPs in short) in this matter.

3.      This case pertains to repudiation of a medical claim of son of the Complainant No. 1, Anshuman Rai. The rejection as notified by email dated 07.06.2017 was contested by the Complainant as unjust. He was also aggrieved by the premature termination of the health Insurance Policy effective from 27.05.2017 to 27.05.2018.

4.      The matter in brief is that Complainant No. 1, his wife, and their son, Anshuman Rai, obtained a health insurance policy from the OP vide policy number P/231100/01/2014/001530, valid from 28.02.2014 to 27.02.2015. The total premium paid was Rs.18,719/. Identity Cards were issued for the Complainant (No. 3402889 -1), his wife (No. 3402889-2), and son Anshuman Rai (No. 02889-3). However, no insurance policy document was issued by the OP. Thereafter, this policy was renewed several times from 28.02.2015 to 27.02.2018, with no pre-existing diseases declared. Anshuman Rai (Complainant No.2) was born on 08.08.2011 with no congenital anomalies. Later, the Complainant No.1 noticed some spots on his son's back and consulted Medanta Global Health Pvt Ltd on 22.06.2016. Medical examination revealed the presence of café-au-lait spots and a tuft of hair on his back. Thereafter, an EEG and MRI were conducted, and the impression was diagnosed as neurofibromatosis. On 13.07.2016, Complainant No.1 subsequently consulted Primus Super Specialty Hospital, and after confirming the condition of the child, a surgery was advised. The Complainant No.1 requested cashless treatment at the hospital, which was denied by the OPs/Insurer, leading to the spending Rs.14,75,567/- in Primus Super Specialty Hospital and Rs.29,510 in Medanta Global Health Pvt Ltd.

5.      The Complainant alleged that this disease was not a genetic or birth defect, as it was not present in any family member, and he only became aware of it during the consultation at Medanta Global Health Hospital. The insurance policy's terms and conditions did not exclude pre-existing conditions, and the Complainant No. 1 believes the denial of the claim by the OPs/Insurer is unjust. Complainant No.1 contacted t