No Proof Of Pre-Existing Disease: Delhi State Commission Dismisses Religare Health Insurance Appeal
The Delhi State Consumer Disputes Redressal Commission, comprising Justice Sangita Dhingra Sehgal (President) and Bimla Kumari (Member), has held that an insurance claim cannot be repudiated merely on suspicion of a pre-existing disease in the absence of cogent medical evidence. The Commission, while dismissing the appeal filed by Religare Health Insurance Co. Ltd., observed that symptoms or tentative hospital records do not establish concealment, especially when diagnostic tests do not confirm the disease, and upheld the finding of deficiency in service in favour of the complainant.
Brief Facts
The complainant, Subhash Chand Gupta, had obtained a mediclaim policy from Religare Health Insurance Co. Ltd.(Opposite Party) for a period of two years by paying a premium of ₹49,783. At the time of availing the policy, the complainant disclosed that his wife was suffering from hypothyroidism, and the insurer issued the policy after conducting a medical examination.
On 25.06.2015, the complainant's wife developed chest pain and was admitted to Max Hospital, where she underwent clinical evaluation including angiography. She was discharged in a stable condition, and no conclusive diagnosis of the alleged diseases was made. The complainant incurred medical expenses of about ₹74,219 towards treatment and post-hospitalisation care.
The complainant submitted a claim for reimbursement; however, the insurer repudiated the claim on 27.08.2015 on the ground that the insured had concealed pre-existing diseases, namely Chronic Obstructive Pulmonary Disease (COPD) and dyspnea on exertion (DOE), thereby violating the policy terms.
Aggrieved, the complainant approached the District Commission, which allowed the complaint and directed the insurer to pay ₹74,219 along with interest @5% per annum in case of default, and ₹25,000 as compensation for wrongful repudiation.
The insurer challenged this order before the State Commission.
Contentions of the Insurer
The insurer contended that the claim was rightly repudiated as the insured had suppressed material facts regarding pre-existing diseases at the proposal stage. It relied on medical records indicating a history of COPD and dyspnea on exertion and argued that the policy was governed by the principle of utmost good faith.
Observations and Decision
The Commission observed that the insurer, Religare Health Insurance Co. Ltd failed to establish that the insured was suffering from any pre-existing disease at the time of obtaining the policy. It noted that the medical records relied upon by the insurer merely reflected symptoms or tentative history and did not constitute confirmed diagnosis.
It further observed that subsequent clinical tests, including angiography, did not establish the existence of COPD or dyspnea on exertion. The presence of tentative entries or suspicion in medical records cannot be treated as proof of disease. The Commission held that the burden of proving concealment lies on the insurer, which was not discharged.
The Commission also noted that the policy had been issued after conducting a medical examination, and therefore, repudiation based on unsubstantiated allegations lacked factual foundation. It emphasised that insurance contracts are standard-form contracts, and policyholders cannot be expected to comprehend every clause, especially when the insurer itself undertakes medical evaluation before issuing the policy.
Finding no infirmity in the District Commission's order, the State Commission upheld the finding of deficiency in service and dismissed the appeal.
Case Title: RELIGARE HEALTH INSURANCE CO. LTD. VS. MR. SUBHASH CHAND GUPTA
Case Num.: FA/356/2023