Present: Ms. Vijay Laxmi, proxy counsel for the Mr. Pankaj Seth, 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:

“

1. The complainant has filed the present complaint praying for Rs.3,00,000/- towards cost of treatment and medicines spent in Max Hospital for the treatment of his wife and on account of physical and mental torture and harassment, litigation expenses.

2. It is stated by the complainant that he had taken a Mediclaim policy from the OP vide policy no. 10233187 for a period of two years and paid the amount of Rs. 49,783/- as premium.

3. It is stated by the complainant that the policy was given to him by the OP, after getting medical examination conducted. In the proposal form, the wife of the complainant had clearly disclosed that she was suffering from Hypothyriodism.

4. The wife of the complainant suffered from pain in chest and was admitted to the hospital on 25.06.2015 and was rushed to Max hospital Patparganj where the doctor after considering her stage, advised her to be admitted in the hospital.

5. Clinical examinations were conducted by the hospital particularly for heart disease and angiography was also done and she was discharged on 29.06.2016 in a stable condition. It is stated by the complainant that no pre-existing disease of any kind was found by the doctors and it was realised that the pain was sudden. In this regard, all the documents pertaining to the hospital have been annexed as Annexure 2.

6. It is further stated by the complainant that the total amount incurred by him on the expenditure of treatment of his wife was Rs. 74,219.84/-. It is also stated that after being discharged he spent huge amount on the medicines as advised, by the doctors which is also within the purview of post hospitalization expenses in terms of insurance policy provided by the OP.

7. It is stated by the complainant that he requested the OP several times to pass his claim however, his claim wast rejected on 27.08.2015 vide letter annexed as Annexure 6 on the ground of disease, pre-existing.

8. It is the case of the complainant that dishonest and malafide intention of the OP is clear from the repudiation letter as they have fabricated grounds by taking the shield of clause 6.1 of the policy which states that the policy shall be cancelled or claims shall be repudiated if the policy holder has concealed or withheld any information maliciously or with dishonest intention.

9. It is stated by the complainant that there has been no withholding of information or concealment from his side at the time of taking the policy which is evident from the fact that the wife of the complainant had fully disclosed that she was suffering from thyroid at the time of taking of insurance policy and this fact is also substantiated by the medical examination conducted by the OP on the complainant and his wife at the time of taking the policy.

10. The complainant has stated that in case there was any pre- existing disease at the time of taking of the policy then it would have detected at the medical examination which was got conducted by the OP at the time of taking of policy. Therefore, it is stated that the policy has been wrongly repudiated.

11. Per contra, the OP in their reply have stated that the complaint is not maintainable as there has been no deficiency in service on the part of the OP in rejecting the claim of the complainant

12. It is stated by the OP that the claim was rightly repudiated as there was a non-disclosure of chronic obstructive pulmonary disease (COPD) and dyspnea on exertion (DOE) for last 6 months for Ms. Bala Gupta. It is stated that the following non- disclosure came to the notice of the OP from the documents of OPD consultation sheet dated 06.12.2014 from Garg hospital, Delhi wherein it is mentioned that the patient is suffering from dyspnea on exertion (DOE) chronic obstr