Passed  by Shri Atul D. Alsi, Hon’ble President.

1. The complainant fled complaint case against repudiation of insurance claim medical claim for the reason of pre existing disease and thereby claiming insurance amount of Rs.159117/- along with interest @18 % and compensation of Rs.50,000/- alongwith cost of litigation of Rs. 10,000/-
2. The complainant purchase mediclaim policy bearing NO. 13-19-0010057-00, from O.P. insurance company against the premium paid Rs.16,738/- for the period between 17-5-2019 o 16-5-2020 for complainant himself as family members.  After submission of proposal form with relevant information and after necessary medical tests and diagnosis suggested by insurance company.
3. In the months of April -2020 the suddenly complaint experience sever pain in his limbs of finger of his right hand. The colour of finger was also change due to irregular of circulation of blood.  After diagnosis by Shilendra Gunjewar at Kingsway hospital Nagpur, the complainant is suffering from right upper limb thus ischemia and pre-gangrenous change in his right upper limb fingers. The complainant thereafter undergone surgery on dated 14.4.2020 and discharged on dated 18.4.2020 and spent Rs.1,55,200/-towards medical expenses. Thereafter the complainant submitted the insurance claim but the O.P. has repudiated the insurance claim for the reason of treatment of pre-existing disease of hypertension and therefore there is suppression of material fact as per repudiation letter issued on dated 26.7.2020.  The complainant submitted that at the time of obtaining policy the complainant has disclosed in respect of hypertension in proposal form and it is not necessary that hypertension person is necessarily suffer of ischemia.  Ischemia is one of the Clot in vein which disturbs the blood circulation to the affected area. The complainant has not suppressed any material disease from O.P. Therefore rejection of insurance claim does amount to deficiency of service, therefore present complaint is filed.
4. After filing of complaint notices were issued to O.P. No.1 and 2.  O.P. 1 & 2 present through their counsel and filed reply.  O.P.No.1 and 2 are admitted the insurance policy of complainant and denied the allegation against them, and further submitted that, after filing of insurance claim by complaint and after verification of medical document it is clear that insured had pre-existing medical condition such as hyper-tension since last 20 year and fissure since 12 year which was concealed and suppressed by the complainant at the time of availing the insurance policy as per discharge summery filed with insurance claim. The policy is issued on the basis of discloser in proposal along with associated documents. Therefore rejection of claim does not amount to deficiency in service on the part of O.P. as per letter of repudiation dated 26.7.2020.
5. The counsel for complaint Mr. Anand S. Joshi argued that the complaint has disclosed the disease of hypertension in proposal form and the complainant was not suffering any ailment, chronic disease or disorder except hypertension.  After surgery the insured discharged on dated 18.4.2020 by paying medical bill of Rs.1,44,201/-.The ischemia and hypertension are not co-related with each other.  Both diseases are different and its treatment is also different. It is not necessary that each hypertension patient will suffer from ischemia nor it is necessary that each ischemia patient have history of hypertension. The insured disclosed information of hypertension in proposal form, therefore rejection insurance claim for the reason of pre-existing diseased of hyper-tension does amount to deficiency of service.
6. The O.P.NO.1 and 2 as per receipt medical documents and bill from the Kingsway Hospital, Nagpur after surgery and after careful verification of medical documents it is clear that the insured has pre-existing medical condition as hyper-tension since last 20 year.  Therefore non discloser of pre-existing disease does amount to breach of term of utmost good faith between the parties, therefore rejection of claim does not amount deficiency of service.

From the complainant and written submission made by the parties and documents filed on record the following points arose for consideration.

REASONING

7. The basic dispute of repudiation insurance policy as per repudiation letter issued by O.P. on date 20.4.2020 is in respect of pre existing disease of Hypertension at the time of purchase of policy not mentioned and therefore there is a breach of terms and condition of policy, and utmost good faith.  At the time of purchasing of policy the insured who is a consumer by purchasing policy has disclosed the required information and fact of disease of hypertension.  After medical examination and pathology test the medi-claim policy has been issued to the insured. The O.P. has not filed any opinion of medical doctor on affidavit as evidence that hypertension is co-related with ischemia , as the treatment for both disease are different. It is admitted fact that it is not necessary each hyper tension patient will suffer from ischemia nor it is necessary each ischemia patient have history of hypertension. Therefore rejection of claim for non discloser of disease of hypertension does amount to suppression of material fact and therefore the complainant is entitled for the insurance claim of  Rs.1,44,201/- alongwith interest @ 7% from the admission of complaint that is 12.2.2021 till realisation alongwith compensation for mental torture amounting to Rs.25,000/- with cost of litigation to Rs.10,000/- as per following order. 

 ORDER

1. Complaint is partly allowed.
2. O.P.Nos.1 & 2 are directed to pay the complainant Mediclaim insurance policy claim amount of Rs. Rs.1,44,201/- alongwith interest @ 7% p.a. from the admission of complaint that is dated12.2.2021 till realisation.
3. O.P.Nos.1 & 2 are directed to pay the complainant compensation for mental torture amounting to Rs.25,000/- with cost of litigation of  Rs.10,000/-
4.  Copy of order be furnished to both the parties free of cost.