Dtd.18.05.2023                                                   A/175/2021

O R D E R

HON’BLE Mr.JUSTICE HULUVADI G RAMESH : PRESIDENT

1.    This is an appeal filed U/s.41 of CPA 2019 by OP/Appellant aggrieved by the order dtd.16.12.2020 passed in CC/36/2019 on the file of Bidar District Commission.
2. The Commission examined grounds of appeal, impugned order, appeal papers and heard the learned counsels.
3. It is not in dispute that Complainant having obtained health insurance policy from OP in the year 2016, is getting renewed continuously from 2016 to 2020 by paying prescribed premium. In the year 2019, since he was suffering severe back pain, he undergone all necessary investigations in Virinchi Hospital, Hyderabad and the OP initially sanctioned Rs.3 lakhs for the expenses incurred therein. However, upon enquiry, when OP came to know that Complainant has chronic neck pain – tingling paresthesias of hands since 3 years rejected subsequent claim of Rs.3,23,034/- on the ground that pre-existing ailments not disclosed at the time of proposal, thereby complaint came to be raised, wherein Commission below enquired into the matter and proceeded to allow the complaint directing OP to pay Rs.3,06,648/- with interest at 8% p.a. along with compensation of Rs.20,000/- and cost of Rs.2,000/- by appreciating Ex-P5/discharge summary and Ex-P5/final medical bill issued by Virinchi Hospitals, Hyderabad and recorded its affirmative findings in para 14 as: ……It is clearly mentioned that in regard to renewed policy of 2019 the Chronic Neck Pain Tingling Paresthesias of hands since one year. But, the complainant has renewed his policy previously with the continuation of health renewal policy per year from 12.04.2016 onwards. The complainant is renewing the policy since 2016 and it was valid when he undergone treatment in the Virinchi hospital. This would further become significant in the discharge report Ex.P.9 which is a final bill given for Rs. 3,06,648/-. When the complainant is getting renewal of the health insurance policy continuously from the year 2016-17, 2017-18 and 2018-19 from the month of April to April and final renewed policy from April- 2017 to April-2020. Therefore we are of the opinion that based on the medical report if at all if there had been suppression, the complainant would have misused his health policy in the year of April-2017 only. But it is only in the 2019 because of his occupation of work sitting before computer or any other sedentary life while the disease as stated affected him and so he obliged to take treatment at Virinchi hospital, Banjara Hills, Hyderabad. It is seen when the medical records seen carefully that we do not find the complainant suppressed his disease to make a false mediclaim against the Respondent’s Insurance Company. The evidence of P.W.1 further strengthen the case combined to read the medical records to set up a genuine claim against the Insurance Company. …. the Respondent’s Insurance Company taking the defense which is not based on medical records and only simply denying the claim of the complainant without any valid documentary evidence, which does not call for interference of this Commission for the grounds set out in the appeal. In the result, we proceed to dismiss the appeal with no order as to cost.    
4. The amount in deposit is directed to be transferred to the District Commission for needful. 
5. Notify copy of this Order to the District Commission and parties.

          Judicial Member                              President

*GGH*