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2026 Supreme(Online)(SCDRC) 2771
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
B. Sudheendra Kumar, President, Ajith Kumar D., Judicial Member
DR MARIA JAYA VEDAMONY – Appellant
Versus
ICICI -LOMBARD INSURANCE COMPANY LTD – Respondent
Consumer Complaint No. SC/32/CC/251/2017
For the Appellants/Petitioners: B. Vasudevan Nair
For the Respondents: Prasanna Kumar Nair
An insurance company cannot repudiate a medical claim for alleged non-disclosure of a pre-existing disease when medical records clearly indicate that the condition was diagnosed after the inception of the insurance policy.
Headnote:(A) Consumer Protection Act, 1986 - Section 17 - Health Insurance - Repudiation of claim - Allegation of non-disclosure of pre-existing disease (osteoarthritis) - Hospital records confirmed diagnosis was subsequent to policy inception - Repudiation based on unsubstantiated allegations constitutes deficiency in service. (Para 17)
Facts of the case:
The complainant purchased a health insurance policy and later underwent double knee replacement surgery. The insurance company repudiated the claim, alleging the complainant failed to disclose a pre-existing medical condition (osteoarthritis) existing six years prior to the policy inception. The complainant contended that the condition was diagnosed only after the policy was issued and proved with medical documents.
Findings of Court:
The court observed that medical records did not substantiate the claim of pre-existing osteoarthritis. Documentary evidence confirmed that the diagnosis was made after the policy inception. Consequently, the repudiation was held as not justified, amounting to a deficiency in service.
Issues: Whether the repudiation of the medical insurance claim based on non-disclosure of a pre-existing disease was valid.
Ratio Decidendi: Insurance companies cannot repudiate a claim for non-disclosure of a pre-existing disease based on mere assertions when medical evidence confirms the disease was diagnosed subsequent to the issuance of the insurance policy.
Result: Complaint allowed in part.
| Table of Content |
|---|
| 1. factual background regarding insurance policies and subsequent claim denial. (Para 2 , 3 , 4 , 5 , 6) |
| 2. procedural history and points of consideration for the commission. (Para 7 , 8 , 9 , 10 , 11 , 12) |
| 3. analysis of evidence finding no pre-existing disease as alleged by the insurer. (Para 13 , 14 , 15 , 16 , 17) |
| 4. final award for refund of treatment expenses and compensation for deficiency in service. (Para 18) |
ORDER
KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, VAZHUTHACAUD, THIRUVANANTHAPURAM
C.C. No. 251/2017
ORDER DATED: 08.04.2026
PRESENT:
HON’BLE JUSTICE SRI. B. SUDHEENDRA KUMAR : PRESIDENT
SRI. AJITH KUMAR D. : JUDICIAL MEMBER
COMPLAINANT:
Dr. Marlene Jaya Vedamony, VP/X/737, Jehovah Jireh, Ponnambi, Vellarada, Thiruvananthapuram-695 505 (By Adv. B. Vasudevan Nair)
Vs.
OPPOSITE PARTY:
ICICI-Lombard Insurance Company Limited, ICICI-Lombard Health Care, ICICI Bank Tower, Plot 12 Financial District, Nanakram Guda, Gachibowli, Hyderabad-500 032, Andhra Pradesh (By Adv. Prasanna Kumar Nair)
ORDER
HON’BLE JUSTICE SRI. B. SUDHEENDRA KUMAR : PRESIDENT
This is a complaint filed under Section 17 of the Consumer Protection Act, 1986.
2. The complainant and her husband are alumni of Christian Medical College, Vellore. They worked at various hospitals all over India and thereafter they decided to come back to Kerala and settle in their home-town at Thiruvananthapuram. The opposite party approached the complainant and encouraged the complainant and her husband to take accident insurance policies for Rs. 20,00,000/- each. Accordingly, the complainant and her husband decided to take policies for Rs. 20,00,000/- each. However, both the said policies were issued in the name of the husband of the complainant alone. Due to the vigilant and repeated enquiries for over eight months, the opposite party had corrected the mistake and issued independent insurance policies to the complainant and her husband. Thereafter, the complainant had taken family health insurance policy for the complainant as well as her daughter on 21.10.2014. Six months after taking the policy, the opposite party on 15.04.2015 informed the complainant that the policy issued to the daughter of the complainant was a top-up policy and hence, in order to get the full benefits of the health insurance policy, the complainant had to take a base policy. In the said circumstances, the complainant decided to cancel the policy issued to her daughter. Thereafter, due to the continuous insistence of the opposite party, the complainant reconsidered the decision to cancel the policy. As the need for health insurance was the paramount consideration, the complainant decided to apply for a health insurance again with the opposite party for herself and for her daughter. The complainant applied for top-up and base health insurance policies for the complainant and her daughter.
3. While so, due to the discomfort to the knees of the complainant, the complainant had consulted with the Department of Orthopedics at Dr. Somervell Memorial CSI Medical College Hospital, Karakonam. On 10.07.2015, the complainant was diagnosed with osteoarthritis on her left knee. Thereafter, it was found that the right knee was also having some discomfort. Eventually, the complainant had to undergo a surgery for the replacement of both the knees on 22.06.2017 at Christian Medical College Hospital, Vellore, believing that the policy issued to complainant would cover the treatment and surgery. Prior to the surgery, the complainant repeatedly contacted the opposite party. The opposite party assured the complainant that since the Christian Medical College Hospital, Vellore was a paneled hospital, the complainant would be given cashless service with a limit up to Rs.8,00,000/-. The opposite party also informed the complainant that there should be a minimum cost of Rs.3,00,000/- in order to avail the insurance policy. As the complainant had to undergo a double knee replacement surgery, the c
