Indian Kanoon - Search engine for Indian Law

2. It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Commission. Facts of the Complaint

3. Brief facts, as averred in the complaint, are that complainant No.2 is daughter-in-law of complainant No.1. She took Overseas Mediclaim Insurance Policy under plan namely "EXPLORE CANADA +" for travel period of 179 days, as a proposer on the life of Harwant Singh, complainant No.1 and his wife, Parvinder Kaur (mother-in-law of complainant No.2) as insured from the authorized agent. Proposal Form No.4100100090584 was filled and Insurance Policy bearing No.12347762 was issued, which was valid for the period 12.04.2018 to 07.10.2018 for sum insured of 1,00,000 US Dollar each for complainant No.1 and his wife Parvinder Kaur. The authorized agent of opposite parties obtained signatures of the insured on blank Proposal Form etc. in a mechanical and routine manner. The insurance premium for the above said period was paid. The opposite parties had agreed and undertaken to indemnify the insured for medical expenses for illness/sickness, accident sustained or contracted within the period of insurance. Complainant No.1, insured had perfect good health profile, insurability with no physical impairment and pre-existing disease/illness, except those mentioned in the Proposal Form. He was not afflicted with Hypertension and Hyperlipidemia at the time of taking of insurance policy. It is further averred that the details of the benefits and perils covered in the policy documents, containing terms and conditions and exclusion clauses, were not supplied by opposite parties to the complainants during subsistence of policy. Only the policy acceptance letter and Policy Certificate were issued, but the comprehensive policy was never issued. Complainant No.1 (hereinafter to be referred as "insured") proceeded to Canada. During his stay there, he complained unwellness and consulted Surrey Memorial Hospital. He was admitted there on 11.05.2018 and was discharged on the same day after giving treatment. The insured also took treatment from Medical Cleaning Family Physician and also underwent requisite medical tests. The insured lodged the claim with the opposite parties for reimbursement of the expenses incurred and paid from their own sources and submitted all the bills/cash memos etc. to them. However, the claim was rejected by the opposite parties, vide letter dated 23.07.2018, on the grounds of alleged non-disclosure of pre-existing medical conditions and misrepresentation. The rejection of the claim was illegal, as the insured was not suffering from any pre-existing disease at the time of taking the policy. The opposite parties violated the guidelines issued by the Insurance Regulatory and Development Authority. Alleging deficiency in service and unfair trade practice on the part of the opposite parties, the complainants approached the District Commission, seeking direction to them to pay/reimburse the amount of ₹20 lac towards medical expenses incurred on the treatment of the insured.

"Loss of Appetite, generalized weakness, fever, chills."

No nexus between the above said diseases and Hypertension/ Hyperlipidemia has been proved on record by the opposite parties. The prescription slip dated 09.04.1985 issued by Makkar Hospital, Ex.R-5, pertains to one Harbans Singh and not insured, Harwant Singh. Due to difference of name of the patient, it cannot be said that insured had taken treatment from Makkar Hospital on 09.04.1985 for the ailments mentioned therein. No other medical record has been produced by the opposite parties to prove that the insured was suffering from the above noted diseases prior to taking the insurance policy. Although, as per Discharge Summary, Ex.C-16, the insured was having symptoms of liver abscess as well as possible small right lower lobe lung abscess. It is matter of common knowledge that some ailments can spend decades, lurking in the body of an individual, until they suddenly spring-up in life. Many persons have diseases that they are already having without knowing. The diseases remain dormant in the body for years. Some illnesses have incubation period of anywhere from years to decades. Some diseases wait in the body for decades before striking. Liver abscess and Hyperlipidemia diseases can also remain dormant for many months/years. At any time and at any age, they can strike without warning, changing life forever. In these circumstances, it cannot be said that the insured was having notice of liver abscess and Hyperlipidemia before taking the policy. Furthermore, the Insurance Company was supposed to conduct requisite medical tests to monitor the health status of the insured at the time of filling up the Proposal Form, but there is no such evidence on record to prove that they adopted this practice at the relevant time. The burden of proof was upon the opposite parties to prove that the insured was suffering from above referred diseases prior to taking the policy, but they have miserably failed to discharge this onus, by not leading any cogent and convincing evidence to prove this fact. In case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon'ble National Commission that usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. Thus, the repudiation of the claim on the ground of pre-existing disease was held to be invalid.

8. Learned Counsel for the respondent has contended that as per the terms and conditions of the insurance contract, the Insurance Company was not required to reimburse the petitioner complainant for expenses incurred by him on pre-

existing disease. Learned Counsel has argued that from the medical report of the petitioner, it is clear that the petitioner was suffering from hypertension prior to the purchase of the insurance policy and since hypertension has a direct nexus with heart ailment, the respondent Insurance Company was justified in repudiating the insurance claim in view of the exclusion clause which excluded the expenses incurred on pre-existing disease.

21. It is also relevant to mention here that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that diseases, in question, were pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice.