Repudiation of policy claim on the ground of non-disclosure of material facts, declared improper

National Consumer Disputes Redressal Commission (NCDRC): “Hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack,” observed NCDRC while rendering relief to a person whose insurance cover for Bypass Surgery was repudiated by the insurance company on the ground that the insured was having a history of hypertension which was not disclosed in proposal form. Earlier, complainant purchased an Overseas Travel Insurance Policy from Bajaj Allianz General Insurance Co. Ltd. for sum insured US$ 2,00,000. As per the policy, against one ailment, the maximum insurance cover was 15000 US$ equivalent to Rs.7,50,000/-. During the subsistence of the insurance policy, the complainant complained of chest pain during his stay in London. When he consulted the doctor he was admitted in hospital and underwent Coronary Bypass Graft Surgery at Wellington Hospital, London. The insurance claim of complainant for reimbursement of amount of 12,005 pounds for expenses for surgery and consultation fee etc. was repudiated by the insurance company on the ground that claim was not payable because as per the medical record of the treating doctor / hospital, the complainant was having past medical history of hypercholestremia, Ischaemic Heart Disease as well as hypertension, which were excluded as per the insurance contract. However, when the complainant approached District Forum, an amount of Rs.7,19,500/- was granted to the complainant alongwith Rs.2200/- as litigation expenses. When the insurance company filed appeal against the order of District Forum, State Commission observed that insurance company was justified in repudiating insurance claim because the complainant had obtained insurance policy by concealing the factum of his previous ailment, namely, hypertension, which has a nexus with the heart problem. Being aggrieved by the order of the State Commission, the complainant filed revision petition. NCDRC, after perusing the relevant records and hearing the parties, observed that “the only fact established by the above reports (medical report of the petitioner) is that the petitioner prior to obtaining insurance policy was having history of hypertension. This, however, does not lead to conclusion that petitioner was also having previous history of heart problem. Therefore, the insurance claim submitted by the complainant for treatment of his heart problem cannot be termed as a claim in respect of a pre existing disease. Thus, repudiation of insurance claim by the respondent opposite party is not justified.” “Hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack. Therefore, the argument advanced by respondent is far fetched and is liable to be rejected,” noted the Commission while allowing the revision petition and restoring the order of the District Forum. [Satish Chander Madan v. Bajaj Allianz General Insurance2016 SCC Online NCDRC 28, decided on 11 January, 2016]

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