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DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
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Jaspal S. S. v. National Insurance Co. Ltd.
| Table of Content |
|---|
| 1. facts surrounding the complainant's claim and its repudiation. (Para 1 , 2) |
| 2. arguments regarding the validity of the claim and its justification. (Para 3 , 4) |
| 3. judicial observations and requirements from the insurer regarding evidence. (Para 5 , 6 , 9 , 10 , 11 , 12) |
| 4. core reasoning that lifestyle diseases cannot justify claim repudiation. (Para 7 , 8 , 13) |
| 5. final ruling ordering reimbursement and compliance within a specified timeframe. (Para 14 , 15 , 16 , 17 , 18 , 19) |
1. The facts of the case necessary as per the District Commission record are:
The complainant had a Mediclaim policy from 28.2.2004 to 27.2.2005, sold by OP. On 24.6.2004 the complainant experienced pain in chest and remained admitted in Escorts Hospital from 24.6.2004 to 30.6.2004, where he had undergone Angioplasty and Stenting, by incurring Rs. 3,20,126 on the treatment. He presented the claim to OP. It is alleged that the claim was repudiated on the basis that complainant, as per record was a case of Diabetic for last 15-20 years, and that was a cause of Coronary Artery Disease. It is stated by complainant that, in fact he had been suffering from Diabetic only for 2-3 years, and not since
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