Insurance companies cannot deny claims based on non-disclosure of unrelated pre-existing conditions, as their own actions must not result in loss of coverage.

JUDGMENT

PER : Hon. Smt. Samindara R. Surve, President

1. The present Complaint has been filed by the Complainant against the Opposite Party Insurance Company under Section 34 of the Consumer Protection Act , 2019, for reimbursement of the claim amount of Rs.66,50,000/- with interest, punitive damages, cost etc. on account of the deficiency in service and the unfair trade practice on part of the Opposite Party.

2. Brief facts of the present case are as under;

1. In the year 2017, the Complainant along with his son had purchased a medical insurance policy, bearing no.30718353201700 namely “Heartbeat-Family First Platinum Policy’, having worldwide coverage, from the Opposite Party, which was valid from 27^th November, 2017 till 26^th November, 2018. The sum assured under the said policy was of Rs.65,00,000/- (individual Rs.15,00,000/- + Floater Rs.50,00,000/-) having premium of Rs.72,622/- (1^st policy). The Complainant has stated that under clause 3.5, the Complainant was entitled to reimbursement in respect of the specified illness cover outside the geographical boundaries of India as provided under clause 12.6, only on cash-less facility. Clause 9.6.3 of the said policy provided the Complainant to inform the Opposite Party of the diagnosis of the specified illness before commencement of overseas travel with pre-authorisation. Under Clause 12.76 of the said policy, the Complainant was insured for the ailment of cancer. On 1^st August, 2018, the Complainant was diagnosed with the Colo-rectal cancer, when he was advised to undergo surgery. The Complainant has stated that accordingly he informed the same to the Opposite Party through his agent’s email dated 24^th August, 2018. The Opposite Party was also informed that the Complainant would be travelling to USA for his medical treatment. The Complainant submitted his claim for the treatment taken with Raheja Hospital and Hinduja Hospital as well as in USA to the Opposite Party under the first policy.

3. The Complainant in the meantime renewed the said policy and the 2^nd policy was issued on 15^th November, 2018 by the Opposite Party. However, the Opposite Party by its email dated 17^th December, 2018, repudiated the claim of the Complainant under the 1^st policy on account of non -disclosure of his illness of Asthma and cancelled the 1^st policy on 26^th December, 2019. On being challenged the said cancellation of policy by the Complainant before the Ld. Ombudsman, he by his Award dated 31^st March, 2020 allowed, the claim of the Complainant and directed the Opposite Party to reimburse his claim of Rs.20,47,343/- under the 1^st Policy. The Complainant has stated that he accordingly received the Claim amount from the Opposite Party on 9^th June, 2020.

4. In the meantime, the Complainant kept on taking cancer treatment from USA. The Complainant and his son on 14^th August, 2020, renewed the said policy and the Opposite Party issued the 3^rd policy. The Complainant submitted his bills by email dated 18^th September, 2020 and resubmitted it on 7^th December, 2020 amounting to Rs.88,34,560/- for reimbursement for the hospitalisation and the treatment taken at the Memorial Sloan Kettering Cancer Research Centre, New York for the period 26^th March, 2019 to 31^st March, 2019. However, the Opposite Party by its email dated 6^th March, 2021 rejected the said claim of the Complainant without any grounds. The Opposite Party by its email dated 16^th March, 2021 informed the Complainant that their claim was rejected on the basis of the terms and conditions of the policy. After exchanging several correspondence, the Complainant issued legal no