Failure To Disclose Pre-Existing Heart Ailment, Rajasthan State Commission Dismisses Appeal Against LIC

Brief Facts:

The Complainant and his wife purchased a Health Protection Plus Policy from the Life Insurance Corporation of India (“LIC”), valid from 15.09.2010 to 15.09.2028. They paid Rs. 15,000/- yearly premium after disclosing their medical details to LIC's surveyor during the inspection. The Complainant continued to pay the premiums till 2016. In March 2016, he suffered certain heart problems and was admitted to the National Heart Institute, Delhi for treatment. The doctors diagnosed him with 'Coronary Artery Disease' and recommended him of an operation worth Rs. 2,08,000/-. The Complainant paid the said amount and approached LIC for reimbursement. However, LIC repudiated his claim by giving the reason that he had a pre-existing illness which he failed to disclose during the inspection.

Feeling aggrieved, the Complainant filed a consumer complaint in the District Consumer Disputes Redressal Commission, Churu, Rajasthan (“District Commission”). The Complainant contended that pre-existing ailments can be determined within 2 years. However, the policy was taken in 2010 and the heart ailment was diagnosed in 2016. In response, LIC contended that the Complainant was admitted for a heart condition named 'PTCA with Stenting to ALAD' in 2010. This condition was not disclosed to LIC during the initial inspection. Therefore, the repudiation was valid.

The District Commission ruled in favour of LIC and dismissed the complaint. Dissatisfied by the order of the District Commission, the Complainant filed an appeal in the State Consumer Disputes Redressal Commission, Circuit Bench Bikaner, Rajasthan (“State Commission”).

Observations of the State Commission:

The State Commission perused the Complainant's disease summary issued by the Life Care Institute of Medical Science and Research, Ahmedabad. It mentioned that the Complainant underwent treatment for 'PTCS with Stenting LAD' in 2010. The Complainant was admitted to the hospital for this heart disease just 3 weeks before availing of the health insurance policy.

The State Commission concluded that the Complainant failed to disclose these material facts while availing the policy. Further, he stated that he was not suffering from any heart ailment in the policy form, which constituted a breach of the policy's terms and conditions. As a result, the State Commission dismissed the appeal against LIC.

Case Title: Sushil Kumar vs The Branch Manager, Life Insurance Corporation of India and Others

Case No.: Appeal No. 211/2021

Advocate for the Appellant: Dwarka Das Pareek

Advocate for the Respondent (LIC): Giriraj Mohta

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