Non-disclosure of pre-existing conditions in insurance claims constitutes valid grounds for claim denial.

(Per: Ms. Kumkum Rani, President):

This appeal under Section 41 of the Consumer Protection Act , 2019 has been directed against the impugned judgment and order dated 28.09.2022 passed by learned District Consumer Disputes Redressal Commission, Haridwar (hereinafter to be referred as “The District Commission”) in consumer complaint No. 240 of 2020, styled as Smt. Rekha Rani Vs. Bajaj Allianz General Insurance Company Limited and another, wherein and whereby the consumer complaint was allowed and the appellant / opposite parties (insurance company) was directed to pay an amount of Rs. 1,64,808.39/- to the respondent /

complainant towards medical expenses incurred in her treatment together with interest @6% p.a. from the date of filing of the consumer complaint, i.e., 05.10.2020 till payment, besides to pay Rs. 2,000/- towards compensation and Rs. 2,000/- towards counsel fee & litigation expenses.

2. The facts giving rise to the present appeal, in brief, are, as such that the respondent / complainant had obtained a mediclaim insurance policy bearing No. OG-20-1000-6021-00066419 from the appellant – insurance company, covering self; spouse and two children, for insured sum of Rs. 5,00,000/- by paying premium of Rs. 12,702/- from the complainant’s account with Punjab National Bank, Dhanpura, Haridwar. The aforesaid insurance policy was valid for the period from 29.07.2019 to 28.07.2020. The complainant was having Ayushman Card, under which she was entitled to receive medical treatment at any government hospital or government recognized hospital upto the admissible limit of the card. On dated 01.12.2019, the complainant was detected with ovary cancer, for which she underwent operation at Himalayan Institute Hospital Trust, Jolly Grant, Dehradun on 02.12.2019, intimation whereof was given to the insurance company. An amount of Rs. 3,50,000/- was spent in the treatment of the complainant, besides other related expenses. The required bills were submitted with the insurance company, but the medical expenses were not reimbursed by the insurance company. Without the consent of the complainant and without any intimation to her, on the basis of the documents lying with the appellant, the appellant got any insurance policy of the complainant done from ManipalCigna ProHealth Life Insurance Company, premium whereof was deducted from the complainant’s account with Punjab National Bank, Dhanpura, Haridwar. The policy bond of the said insurance policy was not provided to the complainant. On making final inquiry regarding payment of claim on 10.09.2020, the same was denied by the insurance company. Therefore, the consumer complaint was filed by the complainant before the District Commission.

3. The appellant / opposite parties filed written statement before the District Commission and pleaded that the claim in question had already been disposed of by due application of mind by way of closing the claim, which was conveyed to the complainant vide letter dated 02.02.2021. The terms and conditions of the policy were well explained to the complainant at the time of proposing the policy and the same were furnished to the complainant together with policy schedule. The insurance company has closed the claim of the complainant vide letter dated 02.02.2021 for non-submission of required documents. The complainant has submitted claim form, wherein the total claimed amount was mentioned as Rs. 65,731/-, whereas in the consumer complaint, the complainant has claimed the exaggerated amount.

4. Learned District Commission, after hearing the parties and after taking into consideration the material available