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5. In this case, there is breach of policy conditions done by non - disclosure of the medical history of the plaintiff . According to the defendant, plaintiff (insured) is a known case of COPD (Chronic Obstructive Pulmonary Disease), Type - II, Diabetes Mellitus, Coronary Artery Disease but the same was not disclosed at the time of purchase of policy. It is admitted that insured / plaintiff was hospitalized on 12.01.2021 during the first policy for the treatment of chest pain and palpitation. From the discharge summary, it came to be known that patient (plaintiff ) had a past history of K/C of DMT 2 (i.e. Type II diabetes mellitus and hypertension ). Plaintiff lodged the claim on 22.01.2021 against the Policy No. PTO-12-20-7000480-00-000 for Rs. 1,42,323/- which was rejected by the insurer. The plaintiff got hospitalized with the same complaint in January 2021 and lodged the claim of Rs.57,172/- and the same was also rejected as the previous claim was rejected. The defendant company claims to have been misled due to non-disclosure of material facts and accordingly claim had been repudiated. The clause from the insurance policy terms and conditions has been mentioned as below:-

5. legal notice dated 14.07.2021 Ex.PW1/5

6. Postal receipts along with its tracking report of legal notice are Ex.PW1/6 and Ex.PW1/7.

7. Copy of letter dated 04.08.2021 with respect to the recovery of claim Mark D.

9. During cross examination, plaintiff stated that he has no knowledge if medical certificate is required to be furnished while subscribing to insurance policy in case insured is more than 50 years old. Plaintiff was not suffering from major ailment prior to subscribing to the insurance policy nor he was suffering from blood pressure or diabetes. Plaintiff came to know about his heart condition in January 2021. Plaintiff is not aware if any ailment in the nature of diabetes and with regard to heart condition becomes progressive with age. Discharge summary dated 13.01.2021 is admitted as Ex.PW1/C (colly) and mark C discharge summary of 30.01.2021 contains indication about past history of ailments. Plaintiff is having no knowledge about COPD/CAD/Post PTCA with regard to discharge summary dated 21.06.2021. The plaintiff was not apprised about the terms and conditions of the insurance policy. Plaintiff has denied the suggestion that he lied to the agent and failed to disclose to the insurance company that he is suffering from COPD (Chronic Obstructive Pulmonary Disease). Plaintiff has denied that he failed to disclose true and correct facts to the insurance company before subscribing to the insurance policy or that his claim is not maintainable.

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10. DW-1 Shiv Mohan Singh Chauhan, Zonal Operation Incharge examined himself as DW-1 on behalf of defendant company by way of affidavit Ex.DW1/A and relied upon the following documents:-

1. Policy schedules Mark A and Aa

2. Claim form and discharge summary Mark B and C

3. Claim form Mark D and E

4. Repudiation letter dated 25.09.2021 Mark F and G.

11. During cross examination, DW-1 stated that they got the checkup of insured prior to issuing the policy but they have not got the medical checkup of the insured / plaintiff. It is admitted that they have doctors on the panel. The knowledge of COPD disease of the plaintiff / insured was known when the claim was lodged. The suggestion is denied that it is mandatory to conduct the medical check up before issuing mediclaim policy.

It is admitted that second policy was issued knowing that insured was already suffering from COPD disease. It is admitted that all the documents regarding medical treatment and bills of hospitalization as well as other expenses towards treatment were submitted by the plaintiff with the company. Witness is not knowing that expenses submitted as claim total comes to Rs. 4,47,018/-. It is admitted that defendant has not placed on record the terms and conditions of the policy. The suggestion has been denied that insured has not misled the defendant and it is page no. 7 of 16 admitted that policy has been issued on the basis of proposal form filled by the insured. The suggestion is denied that plaintiff has not misled the defendant company or that plaintiff has not done any wrong. DW-1 voluntarily stated that plaintiff has provided wrong information at the time of getting policies.