923/2011
This petition was filed by the respondent Insurance Company before the National Commission challenging order dated 23.12.2010 passed by Haryana State Consumer Disputes Redressal Commission (for short “the State Commission”) in Appeal No 1792/09.
The claim was repudiated by the insurance company vide letters dated 1.10.2008 and 8.12.2008, respectively on the ground that the appellant’s wife was suffering from rheumatic heart disease and the same was not disclosed in the proposal form.
While entertaining the revision petition filed by the Insurance Company against the order passed by the State Commission, the National Commission vide interim order dated 13.5.2011 directed that the renewal of insurance policy shall be subject to its final decision.
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The said policy was renewed in October 2011 for the period from 7.7.2009 to 6.7.2010 on payment of premium of 6105 and for the period from 7.7.2010 to 6.7.2011 on payment of 30,560 and for the period from 7.7.2011 to 6.7.2012 on payment of 30,560.
The stand taken by the insurance company before the District Forum was that the renewal of the policy was in terms of the order passed by the District Forum in the earlier complaint filed by the appellant as confirmed by the State Commission.
Though the direction was issued by the District Forum, as upheld up to the National Commission, the expenses incurred during the period 7.7.2007 to 6.7.2009 were directed to be paid to the appellant considering the fact that the concealment of rheumatic heart disease had no relation with ovarian cancer. At this stage, it would be unreasonable to deprive the appellant of the fruits of the policy in the form of claim, despite the fact that more than the normal premium was charged by the insurance company at the time of renewal as extra risk was covered. Interim order passed by the National Commission specifically stated that the renewal will be subject to the final decision and finally the National Commission held that the direction issued by the State Commission for renewal of the policy was not proper. Though that amount is not being disputed by the appellant, however, the claim made for the period during which the policy was renewed in terms of interim order passed by the National Commission will not be admissible to the appellant. A claim of 91,416 was submitted for the expenses incurred for treatment from 19.01.2008 to 11.03.2008. The State Commission observed that even at the time of the first renewal of the policy from 07.07.2008 to 06.07.2009, the insurance company was well aware of the treatment which the wife of the appellant was undergoing, for which the claim had already been submitted. In terms of the interim order passed by the National Commission, the insurance policy was renewed for the period from 07.07.2009 to 06.07.2010 on payment of a premium of 6,105. The claim was submitted by the Appellant on 14.10.2011 which was repudiated vide letter dated 31.01.2012, after which the complaint was filed. The District Forum accepted the complaint vide order dated 01.08.2013 and directed reimbursement of expenses incurred by the appellant. There was no clear answer given by learned Counsel for the respondent insurance company regarding the submission of the claim made by the appellant with its agent on 10.03.2008 which was even allotted a claim number 2771734. The National Commission in Revision Petition 923 of 2011 set aside the direction issued by the lower authorities for renewal of the policies beyond 06.07.2009, as it was noticed that there was concealment of facts by the appellant at the time of purchase of the policy with reference to the disease already suffered by his wife i.e., rheumatic heart disease.
The main thrust of the argument of learned Counsel for the insurance company is that in terms of the guidelines issued by the Insurance Regulatory and Development Authority on 31.03.2009 regarding renewal of health insurance policies, the renewal of policy to the appellant could be refused.
The rejection of the claim on the ground that there was concealment of certain material facts by the appellant at the time of purchase of policy, was not found to be tenable and the insurance company was directed to reimburse the expenses incurred for the period from 07.07.2007 to 06.07.2009.
Case Title: OM PRAKASH AHUJA Vs. RELIANCE GENERAL INSURANCE CO. LTD (2023 INSC 598)
Case Number: C.A. No.-002769-002770 / 2023
