IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution: 18.04.2019 Date of Hearing: 10.01.2024 Date of Decision: 24.04.2024 FIRST APPEAL NO.-227/2019 IN THE MATTER OF NATIONAL INSURANCE CO. LTD., THROUGH: MR. RAGHUNATH PAWAR, AO NATIONAL LEGAL VERTICAL, 2 E/9, THIRD FLOOR, JHANDEWALAN EXTENSION, NEW DELHI - 110055.

(Through: Ms. Geeta Malhotra, Advocate)

Appellant VERSUS MRS. SUMIT KOHLI (DECEASED), W/O. SHRI DINESH KOHLI, R/O 1/56, PUNJABI BAGH, DELHI - 110026.

(Through: Ms. Bhaskar Nayak, Advocate)

…Respondent CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

HON’BLE MS. PINKI, MEMBER (JUDICIAL)

Present: Ms. Geeta Malhotra, counsel for the Appellant.

None for the Respondent.

PER: HON’BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT JUDGMENT

1. The facts of the case as per the District Commission record are as under:

“…The complainant had been insuring herself against medical risks including hospitalization and critical illness for a long time in the past and had taken policy since 2008. Unfortunately on 30.05.2012 following some manifestations when she complained of pain in her chest, during investigation it was found that she had cancerous Metastatic Bone Disease in Multiple sites in the bones. It is further alleged that complainant had past history of cancer because in the year 2004 she was diagnosed with breast cancer for which she received treatment. She was completely cured of disease and led disease- free nearly eight years at a stretch. It is a case of complainant that the condition encountered by complainant was covered under both the policy namely medical policy and critical illness policy and that OP was bound to bear hospitalization charges and to pay the sum insured of Rs. 3,00,000/- under its policy of medical illness. It is further stated that OP no doubt paid claim under medical claim policy however refused its liability under critical illness policy. The complainant wrote letter to OP in this regard but all in vain.”

2. The District Commission after taking into consideration the material available on record passed the order dated 15.03.2019, whereby it held as under:

“We have heard the Ld. Counsels for the parties. The controversy revolves around the issue as to whether the complainant is entitled to the relief claim or not. The answer is in the positive. The sole ground of repudiation by OP appears to be the pre- existing disease having been suffered by the complainant. Needless to say that the policy issued by OPs is not in dispute. It has come on record that complainant suffered the cancer disease in 2004 which was completely cured. This has been so reported to by the treating doctor. It is now well settled law pre-existing disease is one which happened soon before the Inception of the policy. If the disease happened 5-10 years ago it can never be stated to be a pre existing disease. Hon'ble National Commission in case II(2005)CPJ 747 (NC) titled New India Insurance Co. Ltd. Vs Bimlesh has held as under:-

Medi-claim Policy Repudiation of claim concealment of pre-existing disease alleged-complaint allowed by District Forum Non discloser of disease for which Insured was treated 15/20 years before, not amounts to concealment of fact-word" existing means disease which exist at time of taking the policy -OP should have ensured that person in whose favour policy was being given was entitled to same or not. Contributory negligence on part of OP cannot be ruled out OP liable under policy. Order of favour upheld."

Keeping in view the above discussion stated above we award sum insured Rs. 3,00,000/- in favour of complainant to be paid within 45 days from receipt of this order failing which interest @ 6% from the date of institution of complaint till realization shall be levied. The complainant is also awarded a sum of Rs. 10,000/- towards mental agony, harassment and litigation expenses.”

3. Aggrieved by the aforesaid order of the District Commission, the Appellant/Opposite Party has preferred the prese