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Family Health Optima Insurance 2017, which was commenced from 22.07.2018 and was valid upto 21.07.2019 as the said policy was to cater their health-needs. OP No.3 had assured the coverage of all medical-treatments including the Cashless Pre Authorizations at designated Hospitals and also all the pre-existing diseases/ailments.

They were to get benefits by covering the diseases/ailments listed in the original policy. In the month of September 2018, Amarbir Kaur complainant No.2 wife of complainant No.1 had a fall in the bathroom and her knee got injured. She was already suffering from secondary osteoarthritis since 2016. She had consulted the orthopedic surgeon in February 2019, who straightaway advised her for 'knee replacement'. She got admitted in the NHS Hospital, Jalandhar on 14.02.2019 for knee replacement surgery. Thereafter, she filed her claimed with OPs but the same was rejected. Thus, the complainants themselves had paid an amount of Rs.2,50,000/- for the said surgery/hospitalization. Upon discharge the claim was filed with the OPs and the same was repudiated on 10.06.2019 on the ground that Amarbir Kaur complainant No.2 had not disclosed her pre-existing ailment at the time of port/purchase of the policy. It was also mentioned that as per the terms and conditions of the said ported policy all pre-existing ailments were covered by it. The OPs had repudiated the claim of complainant No.2 on the flimsy ground. Thus, the complaint filed by the complainants with the prayer that OPs be directed to settle the claim by paying an amount of Rs.249,618/- along with interest @ 18% PA from the date of policy till its realization and also to pay an additional Rs.2,00,000/- as compensation for causing harassment and mental agony. Further directed to pay an amount of Rs.20,000/- as litigation expenses.

7. Mr.J.S.Dadwal, Advocate learned counsel for the respondents/complainants has submitted that the respondents/complainants had been insured through OP No.3 i.e. Ajay Mahajan (Agent) and he had assured coverage of all medical treatments including the cash less pre-authorization at the OP designated hospitals and all the pre-existing diseases/ailments. It was evident from the list of continuing-benefits on page 2/3 of Ex.C-1. However, in the month of September 2018, the respondent No.2 Amarbir Kaur had a fall in the bathroom and her knee was injured. She was already suffering from osteoarthritis since 2016. She had consulted the orthopedic surgeon in February 2019 who advised for knee replacement. Respondent No.2 got admitted for knee surgery on 14.02.2019 in the NHS Hospital, Jalandhar and had applied for cashless authorization but the same was rejected by the OP insurers. They paid an amount of Rs.2,50,000/- for surgery/hospitalization. Upon discharge they filed the claim with OPs. However, the said claim was repudiated on 10.06.2019 on the ground that she had not disclosed her pre-existing ailment at the time of port/purchase of the policy. The ported policy's terms had allowed coverage to all pre- existing diseases but all failed, the OP did not review and relent over their repudiation. The respondents were also holding one health policy with National Insurance Company which was being renewed from time to time. However respondents/complainants had prompted through porting of previous policy with National Insurance Company having its inception routed in the year 2014. It is an accepted proposition in insurance para-lance that date of inception does not alter the porting from one insurer to the other. The District Commission had observed that OPs had offered coverage to all the listed pre-existing diseases.

8. By considering the averments made in the Complaint as well as in the reply thereof. The complaint filed by the complainants was allowed order dated 06.07.2022 passed by the District Commission. The relevant part of said order is reproduced as under:-

"8. In the light of the all above, we set aside the OP insurers' impugned rejection as well as repudiation of the complainants' knee replacement hospitalization-claim being unfair, arbitrary (and in contravention to laws of equity and natural justice) and amounting to 'unfair trade practice cum deficiency in service'. Thus, we ORDER the OP insurers to pay the full amount of the impugned claim for total-knee replacement Rs.2,49,618/- as payment of the impugned 'insurance claim(s)' along with other accrued benefits, if any, pertaining to the related policy with interest @ 6% PA w e from the date of filing of the claim besides Rs.10,000/- in lump sum as compensation cum cost of litigation within 45 days of receipt of the copy of these orders."

17. From the bare perusal of the above said documents, it is apparent that the reason of repudiation of claim is a paradox in terms of table No.1 where "No PED declared" is mentioned whereas in table No.2 under the caption of continuity of benefits applicable pre-existing disease has been shown to be covered. Said document has been signed by the authorized signatory OP Company and Gurbir Singh, the complainant.

18. It has been alleged by the appellants/OPs that the complainant No.2 Amarbir Kaur had pre-existing ailment of osteoarthritis. Osteoarthritis is a common problem occurred due to which the bones become weak and brittle. It is not necessary that a knee replacement is required in such cases relating to said disease. In the present case the complainant had fallen and she had to undergo surgery for knee replacement surgery. Meaning thereby it was sudden occurrence/accident, the repudiation of claim on this ground is not justifiable. The impugned order passed by the District Commission is based on proper appreciation of facts and documents available on the record.