Insurance claims cannot be repudiated for nondisclosure of pre-existing conditions if the insurer fails to accurately document disclosed medical information during policy inception.

1. This Appeal is directed against the Judgment and Order dated 20.10.2017 passed by the Consumer Disputes Redressal Forum, North Goa (the Forum, for short) in Consumer Complaint No. 50/2016. The Appellant was the Complainant and Respondent was the Opposite Party (OP, for short) in the said Complaint. Parties shall hereinafter be referred to as per their status in the said Complaint.

2. The Complainant had purchased Smart Health Insurance Policy from the OP for the period from 26.7.2013 to 25.7.2014 and the assured amount was Rs. 2,00,000/-. According to the Complainant, when the executive of the OP was filling up the proposal form, the Complainant had informed him that he had a condition of diabetes mellitus and hypertension since April 2013 and the executive informed him that he will take care to fill up all the necessary details in the proposal form and asked the Complainant to sign the blank proposal form and that the copy of the proposal form will be sent to the Complainant at his address as per Regulation 4(1) of the Notification dated 16.10.2002. The Complainant stated that his voluntary declaration was, however, not recorded in the insurance policy. The Complainant was admitted to Manipal Hospital, Goa from 25.3.2014 to 28.3.2014 as he had bleeding in the rectum and the condition was diagnosed as rectal carcinoma (anal cancer). The Complainant underwent surgery for the same in April and was in the hospital from 21.4.2014 till 2.5.2014. He was once again hospitalized on 3.5.2014 and remained there till 27.5.2014 for Gangrene of the left Colon. The Complainant lodged a claim with Paramount Health Services (TPA) Pvt. Ltd. for Rs. 2,20,000/- and submitted the hospital bills and claim number was allotted as 2515754. However, vide letter dated 7.7.2014, the TPA (Paramount) rejected the claim on the ground that the discharge summary indicated that the Complainant had a similar Complaint since one year and history of diabetes and hypertension which was not disclosed at the time of inception. By email dated 18.7.2014 the OP suggested the Complainant to approach the Insurance Ombudsman. The policy of the Complainant expired on 25.7.2014. The Complainant alleged that he did not take steps to renew the same being discouraged by the ploy used by the OP / TPA to reject his claim and that the executives of the OP persuaded him to renew the policy on 21.8.2014. According to the Complainant, by letter dated 26.8.2014 he clarified that history of diabetes and hypertension was since April 2013 and not from March 2012 as inadvertently written by him in the special instructions note for renewal on 21.8.2014. By covering letter dated 1.9.2014, the OP issued the renewed policy for the period from 27.8.2014 to 26.8.2015 for Rs. 2,00,000/-. The case of the Complainant is that the OP again did not record the voluntary declaration of the Complainant in the policy. The Complainant was again admitted to Manipal Hospital on 24.12.2014. According to the Complainant, he was diagnosed with rectal carcinoid (anal cancer) and treatment of repair of incisional hernia was given and he was discharged on 27.12.2014. The Complainant lodged a claim for Rs. 2,77,155/- with Medi Assit India TPA Pvt. Ltd. and the claim number allotted was 10838164. However, this claim was also rejected vide letter dated 6.3.2015 firstly on the ground that the ailment was pre - existing, secondly on the ground that the Complainant had not disclosed the ailment. The third reason for rejection was that the Complainant underwent Inguinal hernia repair which is not covered in the first two years from the taking of the p