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2025 Supreme(Online)(SCDRC) 1213
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Mrs. Justice Daya Chaudhary, CJ, Ms. Simarjot Kaur, J, Mr. Vishav Kant Garg, J
The Oriental Insurance Company Ltd. – Appellant
Versus
Sh.Ravinder Kumar – Respondent
First Appeal|No.225 of 2023|CC No.129 of 2019
For the Appellants/Petitioners:Sh.Ram Avtar, Advocate
For the Respondents:Sh.Vinay Puri, Advocate
The repudiation of an insurance claim based on pre-existing hypertension is unjustified if the insurer fails to provide evidence of concealment, as hypertension is a common ailment and does not automatically disqualify coverage.
Headnote:(A) Consumer Protection Act, 2019 - Section 41 - Medical Insurance Claim - Appeal against order of District Commission - Claim for reimbursement of medical expenses denied on grounds of pre-existing disease - The court found the repudiation of the claim to be unjustified, emphasizing that hypertension is a common ailment and should not be classified as a pre-existing disease without substantial evidence of concealment. (Paras 20, 22-24)
(B) Insurance Contract - The insurer's obligation to conduct a medical examination for individuals over 35 years was not fulfilled, leading to an improper repudiation of the claim. (Paras 20, 25)
Facts of the case:
The complainant was denied reimbursement for medical expenses incurred due to a heart condition, with the insurer claiming it was a pre-existing condition of hypertension. The complainant argued that he had disclosed his health status accurately at the time of policy issuance.
Findings of Court:
The appeal was dismissed, upholding the District Commission's order to reimburse the complainant for the medical expenses with interest and compensation for mental harassment.
Issues: Whether the insurer had justifiably repudiated the claim based on pre-existing conditions, and whether the complainant had concealed any relevant health information.
Ratio Decidendi: The court ruled that the insurer failed to prove any concealment of a pre-existing disease and that hypertension alone does not warrant claim denial.
Result: Appeal dismissed.
| Table of Content |
|---|
| 1. details of the insurance claim and its rejection. (Para 3 , 4 , 5) |
| 2. response and objections from the insurance company. (Para 6 , 8) |
| 3. arguments by the appellant regarding policy terms. (Para 9 , 10) |
| 4. arguments by the respondent regarding claim justification. (Para 11 , 12) |
| 5. court's review of the case and issues at hand. (Para 16 , 18) |
| 6. clarification on the definition of pre-existing diseases. (Para 21 , 22 , 23) |
| 7. court's ruling on the unjustified claim repudiation. (Para 24 , 25) |
| 8. final decision and order of the court. (Para 27 , 28 , 29 , 30) |
SIMARJOT KAUR, MEMBER
This Appeal has been filed by the Appellant/Opposite Party under Section 41 of the Consumer Protection Act, 2019 (in short ‘The Act’) being aggrieved by the impugned Order dated 08.12.2022 passed by the District Consumer Disputes Redressal Commission Jalandhar (in short ‘the District Commission’) whereby the partly allowed the Complaint of the Complainant.
2. It would be apposite to mention that hereinafter the parties will be referred, as had been arrayed before the District Commission.
3. Briefly, the facts of the case as made out by the Complainant before the District Commission are that the Complainant had obtained a Medical Insurance Policy No.233108/48/2018/2299. The sum assured for the policy was Rs.5 lac. The premiums had been regularly paid by the insured. The policy was valid w.e.f. 07.10.2017 to 06.10.2018. The policy was got renewed from 07.10.2018 to 06.10.2019. The said policy was never got cancelled or terminated by the Complainant. The Complainant had suffered some medical problem on 02.06.2018 and he got himself medically checked at DMC Hospital, Ludhiana as an outdoor patient till 08.06.2018. At that time, BP problem was diagnosed/detected. Thereafter, he suddenly suffered from medical problem of breathlessness for the first time. He was admitted in Dayanand Medical College & Hospital, Ludhiana on 10.07.2018 and discharged on 21.07.2018. During the treatment of the Complainant, AICD (MEDTRONICE, SINGLE CHAMBER) was done on 16.07.2017. The Complainant had spent an amount of Rs.4.29,167.74 towards his treatment. It was covered under Medical Insurance Policy for Rs.5 lac issued by OP. The Complainant had filed his Insurance Claim for reimbursement of the medical expenses but the OP had denied the same vide letter dated 17.12.2018. It was rejected as per clause 4.1 and 4.2 of the terms and conditions of the Insurance Policy. His claim had been rejected on the ground that he was a known case of HTN Since 8 years. The Policy had commenced from 2016 onwards. Therefore, Hypertension (HTN) diagnosed before the inception of the said policy. It was a case of pre-existing disease (PED). The claim for pre-existing disease was payable only after three years of the policy whereas the policy of the Complainant was in its second year thus the claim was not payable as per clause 4.1.
4. It was mentioned in the Complaint that the opinion of the Doctor of DMC, Ludhiana, who attended the Complainant was given as below :
HOSPITAL COURSE: Patient was admitted outside, due to ECG and echocardiography changes shifted to HDHl for further management. BNP was raised. Echocardiography was done which showed detailed cardiomyopathy, severe LVB systolic dysfunction, LVEF-18%, frequent VPE's noted ECG was effective of ventricular bigeminy/VPC's, Brady arrhythmia, AICD (Medtronic, Single Chamber was done on 16.07.2018 Regular ASD was done under all aseptic condition. Patient was managed with antibiotics, ace-inhibitors, inotropes, i/v fluids, antiarrhythmics, amiodarone, beta ockers, Diuretics, PPIs and other supportive measures. Gradually patient improved and discharged in stable condition.
5. It was also mentioned in the Complaint that the claim of the Complainant was declined alleging that the claim was not within the purview of the policy as per its terms and conditions. The rejection of the claim was illegal and arbitrary in the eyes of law. At the time of p
