1 C-25/23

Complaint filed on: 27/02/2023

Complaint disposed on: 25/09/2024

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL

COMMISSION, SOUTH GOA AT MARGAO

Coram: Shri Sanjay Motiram Chodankar, President

Mr. Jayson Rodrigues, Member

Complaint No. 25/2023

Mr. Alvito Tomas Fernandes alias Alvito Laurente Fernandes,
son of late Santana Laurente Fernandes, aged about 75 years,
self-employed, residing at House No. 2922, "Mystical Rose"
Behind Kerkar Hospital,
Aquem Alto, Margao,
Salcete, Goa-403601 (M):-9404143890 …..Complainant

V/S

1. Reliance General Insurance

a company registered under The Indian Companies Act, 1956,
having Corporate Identity Number:- U66603MH2000PLC128300
and having registered office at 6th Floor,
Oberoi Commerce, International Business Park,
Oberoi Garden City,
Off. Western Express Highway, Goregaon (E),
Mumbai-400063.

2. The Branch Manager,

Reliance General Insurance,
Panaji Branch, having office at Shop No. 1117/118,
Gera Imperium II, 1st Floor,
Patto Centre, Panaji, Goa-403001. …..Opposite Party

Complainant present in person at the time of hearings, during arguments and at

the time of judgment.
Adv. James Lopes present for OPs 1 & 2 at the time of hearings, during
arguments and at the time of judgment.

JUDGMENT
(Per Mr. Jayson Rodrigues, Member)

1. This Judgment and Order shall dispose of the Complaint filed under Section
35 of Consumer Protection Act, 2019) [for short “C.P. Act”].
 2 C-25/23

2. This consumer complaint has been filed by Mr. Alvito Tomas Fernandes
(hereinafter referred to as “Complainant") against Reliance General Insurance
Ltd. and their Branch Manager in Panaji-Goa, (hereinafter referred to as
"OPS"). The grievance arises out of the repudiation of medical insurance
claims related to cataract surgeries, along with the subsequent cancellation of
the Complainant‟s health insurance policy, allegedly on the grounds of non-
disclosure of a pre-existing medical condition, hypertension.

The brief facts of the case are as under:

3. The Case of the Complainant: The Complainant was insured under Policy
No. 170792028451000596 with the OPS for the period from 28/10/2020 to
27/10/2021. The Complainant underwent cataract surgery on his right eye on
04/02/2021 and incurred expenses of Rs.47,875/- which he later claimed under
his insurance policy. The claim was initially queried, and the Complainant
provided all necessary documents. However, on 22/03/2021, the claim was
rejected on the grounds of non-disclosure of a pre-existing hypertension
condition at the inception of the policy. The Complainant subsequently
underwent cataract surgery on his left eye on 18/03/2021, incurring Rs.40,160/-
in expenses. This claim was similarly rejected on 11/08/2021, citing the same
reason of non-disclosure of hypertension. The OPS also cancelled the
Complainant's policy. The Complainant stressed that he has been a
policyholder since 2011, and the policy was ported from National Insurance
Company‟s "BOI Swasthya Bima Policy" to the OPS in 2019. At the time of
porting under the Insurance Regulatory and Development Authority of India
(IRDAI) portability guidelines, the continuity of coverage, including pre-
existing diseases, was assured by the OPS agent. The rejection of the claim on
the basis that the Complainant did not disclose his hypertension is unfounded,
as this pre-existing condition should have been covered under the portability
terms. There is no medical nexus between hypertension and cataract surgery,
which the insurance company claimed as the reason for rejection. The
Complainant relied on the 2017 judgment attached to his complaint in
“Kamlesh N. Patel v. Iffco Tokio General Insurance” (Complaint No. AHD-G-
023-1617-1511), where a similar claim was rejected, but the ruling was in
favor of the policyholder. The Complainant asserts that he did not conceal any
material facts and provided all relevant medical history when asked by the
 3 C-25/23

insurance agent. The Complainant alleges that the rejection of his claims is
arbitrary, lacks bona fide, and is an unfair and deceptive practice.

4. The Complainant sought the following remedies from this Hon‟ble

Commission:
(A) For a Judgment and Order of this Hon'ble Court directing the Opposite
Party No. 1 to pay in the hands of the Complainant an amount of Rs. 40,000/-
(Rupees Forty Thousand only), which is the amount payable as per the
insurance policy against the cataract surgery of the right eye undergone by the
Complainant.
(B) For a Judgement and Order of this Hon'ble Court directing the Opposite
Party No. 1 to pay in the hands of the Complainant an amount of Rs. 40,000/-
(Rupees Forty Thousand only), which is the amount payable as per the
insurance policy against the cataract surgery of the left eye undergone by the
Complainant;
(C) For a Judgement and Order of this Hon'ble Court directing the Opposite
Party No. 1 to pay in the hands of the Complainant, an amount of
Rs. 2,00,000/- (Rupees Two Lakhs Only) as compensation for the deficiency in
service, mental stress and agony caused to the Complainant, who is senior
citizen of over 75 years of age.
(D) For a Judgement and Order of this Hon'ble Court directing the Opposite
Party No. 1 to pay to the Complainant, an amount of Rs. 50,000/- (Rupees Fifty
Thousand Only) towards legal expenses incurred by the Complainant towards
consultation and other expenses.
(E) For a Judgement and Order of this Hon'ble Court, directing the Opposite
Party No. 1 to revoke the cancellation of the Policy No. 170792028451000596
of the Complainant, thereby restoring the said policy;
(F) Cost of this complaint be provided for;
(G) Any other Order as this Court deems fit in the interest of justice and as per
law.

5. Complainant has examined himself by filing Affidavit in Evidence in

support of his complaint. He has produced the following documents:

List of documents at Exh. „2‟, Policy Certificates of Insurance at Exh.

„3‟ to „12‟. Health Claim Form dated 25/02/2021 at Exh. „13‟. Discharge
Card by My Eye Hospita Nuvem dated 04/02/2021 at Exh. „14‟. Email
 4 C-25/23

dated 11/01/2021, 05/01/2021 & 12/02/2021 at Exh. „15‟, „16‟ & „17‟.
Bill cum Receipt dated 04/02/2021 at Exh. „18‟. Bill of Supply dated
25/01/2021 at Exh. „19‟, Bill dated 25/01/2021, 23/12/2020 &
20/01/2021 at Exh. „20‟, „21‟ & „22‟, Pre-Operative
Prescrption at Exh. „23‟. Post-Operative Prescription dated 04/02/2021
at Exh. „24‟. Health Claim Form dated 04/08/2021 at Exh. „25‟.
Letter dated 18/03/2021 at Exh. „26‟. Discharge Card dated 18/03/2021
at Exh. „27‟. Email and letter dated 11/08/2021 at Exh. „28‟. Bills
dated 18/03/2021 & 04/02/2021 at Exh. „29‟ & „30‟. Pre-Operative
Prescription at Exh. „31‟. Post-Operative Prescription dated
18/03/2021 at Exh. „32‟. Copy of Award dated 12/04/2017 at Exh. „33‟.
Copy of the Prescription Annexure-1, Copy of Estimate Certificate
Annexure-2, Copy of Medical Fitness Certificate Annexure-3. Copy of
Reference to Medical Specialist Annexure-4, Copy of Item No. 1/67 in
the policy document Annexure-12, Copy of Judgement Annexure-13.

6. The Defense of the OPS, centers on the rejection of two claims filed by the
Complainant for cataract surgeries, citing the non-disclosure of a pre-existing
hypertension condition at the time of policy inception. The Complainant was
insured under Policy No. 170792028451000596, effective from 28/10/2020 to
27/10/2021, and underwent cataract surgeries on 04/02/2021 (right eye, cost:
Rs. 47,875/-) and 18/03/2021 (left eye, cost: Rs. 40,160/-), with claims
amounting to Rs. 88,035/- in total. The OPS rejected these claims, invoking
Clause 5.1.1 of the policy, which voids coverage in cases of non-disclosure of
material facts, and Clause 5.1.2, which permits policy cancellation due to
misrepresentation. It was revealed through claim verification that the
Complainant had been hypertensive for five years prior to the policy's
inception on 28/10/2019, but failed to disclose this condition, leading to the
cancellation of the policy. The OPS pointed that this breach of the duty of
disclosure rendered the claims inadmissible under the terms of the policy,
which is governed by Indian contract law. The OPS emphasizes that the
policy‟s terms were followed in good faith, and the cancellation and rejection
of the claims were justified. Furthermore, the OPS assert that the complaint is
malicious, aiming to pressurize the insurance company into honoring an invalid
claim, and amounts to an abuse of legal process. They stress that honoring such
claims without regard to policy terms would unfairly disadvantage other
policyholders, as insurance claims are paid from a common pool of funds. The
OPS highlights that the insurer‟s responsibility is to ensure that only valid
claims are settled to protect the interests of all policyholders. Consequently, the
 5 C-25/23

OPS seek the dismissal of the complaint, stating that no deficiency in service
exists, and request the dismissal be granted with costs to avoid irreparable
harm.

7. The OPS have filed Affidavit in Evidence in support of defence, and has
produced reply dated 07/09/2023 at Exh. „38‟.

8. Heard the legal arguments presented by both sides and carefully examined
the facts and documentary evidence on record.

9. The issues for determination are whether the non-disclosure of hypertension

constitutes material suppression of facts under the insurance policy, whether
the repudiation of the cataract surgery claims and the cancellation of the
policy were lawful, and whether the Complainant is entitled to
reimbursement, compensation, and reinstatement of the policy.

10. As per the OPS : “Member reimbursement cannot be considered as per received
documents of patient Mr ALVITO LAURENTE FERNANDES admitted in My Eye Hospital from
DOA-18/03/2021 to DOD-18/03/2021 for LE cataract- LE phaco with foldable IOL
implantation. Up on claim verification it is noted that patient is known case of hypertension
since 5 years and the same was not disclosed by insured at the time of policy inception-
28/10/2019. As per policy T&C-under Clause 5.1.1 Disclosure of information nom- The Policy
shall be void and all premium paid hereon shall be forfeited to the Company, in the event of
misrepresentation, miss description or non-disclosure of any material fact. 5.1.2 duty of
disclosure in the event of untrue or incorrect statements, misrepresentation, miss description or
non-disclosure of any material particulars in the proposal form, personal statement, declaration
and connected documents, or any material information having been withheld, or a Claim being
fraudulent or any fraudulent means or device being used by the Policyholder Insured Person or
any one acting on his/ their behalf to obtain a benefit under this Policy, the Company may cancel
this Policy at its sole discretion and the premium paid shall be forfeited in its favor. Hence we
regret to inform you that this claim stands non payable and policy been cancelled”

11.The primary issue in this case revolves around the alleged non-disclosure of
hypertension. The OPS have relied on Clause 5.1.1 of the policy, which
voids the contract if material facts are misrepresented or suppressed. The
crux of the matter, however, lies in determining whether the non-disclosure
of hypertension is "material" in the context of a claim for cataract surgery.
 6 C-25/23

12.The Complainant referenced the Ombudsman‟s award in Kamlesh N. Patel

v/s Iffco Tokio General Insurance Co. Ltd. (Complaint No. AHD-G-023-
1617-1511), wherein a similar claim for knee replacement surgery was
initially rejected due to the non-disclosure of hypertension. The
Ombudsman ruled that there was no nexus between the two ailments and
directed the insurance company to honor the claim. Likewise, in this case,
the Complainant asserts that there is no nexus between his hypertension and
the cataract surgery, making the rejection of the claim unjustified.

13.While hypertension is a common condition among senior citizens, its non-

disclosure must be evaluated based on its relevance to the specific claim.
There is no medical literature or expert testimony before this Commission
that establishes a link between the two conditions (that Cataracts are not
directly caused or worsened by hypertension). Even if a nexus between
hypertension and cataract surgery were assumed, cataracts can occur
independently of hypertension, which is common among individuals
without the condition. The OPS has not demonstrated how the non-
disclosure of hypertension impacted the risk assessment for cataract
surgeries or how it prejudiced the insurer's ability to underwrite the claim.
The rejection of his claims based on vague presumptions of hypertension
affecting the surgery is not bona fide and amounts to a deficiency in service.

14.The regular premiums paid for the policy is undisputed, and the RGI-BOI
Swasthya Product policy explicitly covers cataract surgery per eye up to
Rs.40,000/-. The Complainant‟s good faith in continuing with his policy
payments without any prior major claims is another factor to be considered.
Insurance contracts, especially health insurance, operate on the principle of
“utmost good faith” (uberrima fides), but this principle must be applied with
fairness to both parties.

15.Furthermore, the cancellation of the policy following the rejection of the

claim raises serious questions about proportionality and fairness. In
consumer protection law, insurers are expected to exercise caution and
ensure that they do not exploit minor technicalities to deny legitimate
claims. The failure to disclose hypertension, although a pre-existing
condition, cannot be deemed as a fraudulent or deliberate concealment
 7 C-25/23

when the claim relates to cataract surgeries, an unrelated medical condition.

In this case, the insurer's blanket reliance on the existence of hypertension
as a justification for policy cancellation appears to be a disproportionate
response, given the unproven and unrelated nature of the medical condition
to the actual claim.

16.The OPS approach to voiding the contract after the claim was made, despite
collecting premiums over a sustained period, points towards an arbitrary
interpretation of the policy terms. As per the Complainant the insurer did
not cancel the policy immediately upon discovering the alleged non-
disclosure. The repudiation, therefore, also fails the test of reasonableness.
It is further observed that the insurer could have conducted a more nuanced
assessment of whether hypertension impacted the specific risk that the
cataract surgeries posed and accordingly also enlightened the Complainant.
Without this assessment, the decision to cancel the policy and deny the
claim appears to be a breach of the Complainant‟s consumer rights.

17.The C.P. Act mandates that service providers, including insurers, maintain a
standard of reasonable care and fairness in their dealings with consumers.
This case highlights the vulnerability of senior citizens who place their trust
in insurance companies to safeguard their healthcare needs. The OPS failure
to provide a valid medical basis for linking the cataract surgeries to the non-
disclosure of hypertension, combined with their arbitrary decision to cancel
the policy, constitutes an unfair trade practice. The Complainant, as a senior
citizen, deserves protection from such actions, which undermine his trust in
the system and cause undue distress.

18.The Complainant had ported health insurance policy from National

Insurance to Reliance General Insurance in 2011 as per the IRDA‟s
guidelines on portability. According to Complainant the purpose of IRDA
provision is to ensure continuity of coverage, especially for pre-existing
conditions, which are typically covered after a waiting period in the original
policy.

19.It is come to notice that Health insurance portability allows policyholders to

switch their existing health insurance policies to a new insurer without
 8 C-25/23

losing accrued benefits, such as the waiting period for pre-existing

conditions. Introduced by the Insurance Regulatory and Development
Authority of India (IRDAI) in 2011, this feature ensures that accumulated
benefits, like the sum insured and No Claim Bonus, are transferred to the
new policy. Policyholders may choose to port their policy for reasons such
as insufficient coverage, limitations on room rent, or better benefits offered
by other insurers. The process requires timely renewal of the policy without
any break and submission of necessary documents, including the IRDAI
portability form, identity proof, and medical history. The new insurer must
review the claim history and make a decision within 15 days. However,
portability applications can be rejected due to reasons such as poor claim
history, incorrect information, or failure to meet timelines. Policyholders
must initiate the process at least 45 days before renewal and ensure they
meet the guidelines set by the IRDAI.

20.In this case, the Complainant‟s policy had been continuously in force since
2011, and as per the Complainant the OPS had taken on record the
Complainant‟s previous three years of insurance policies. Therefore, the
Complainant‟s pre-existing condition, including hypertension, should have
been covered under the terms of the ported policy. The OPS trying to color
an image and argument that the policy was initiated in 2019 is incorrect, as
they failed to consider the fact that the policy was ported from a previous
insurer. Hence, the rejection of the claim on this ground is not tenable.

Effective End
Policy No. Effective Start Date Date Policy Name
271201/48/11/8500000921 28.10.2011 27.10.2012 National Swasthya BIMA
271201/48/12/8500001034 28.10.2012 27.10.2013 National Swasthya BIMA
271201/48/13/8500001103 28.10.2013 27.10.2014 National Swasthya BIMA
271201/48/14/8500001172 28.10.2014 27.10.2015 National Swasthya BIMA
271201/48/15/8500001308 28.10.2015 27.10.2016 National Swasthya BIMA
271201501610000596 28.10.2016 27.10.2017 National Swasthya BIMA
271201501710001251 28.10.2017 27.10.2018 National Swasthya BIMA
271201501810001134 28.10.2018 27.10.2019 National Swasthya BIMA
↓ PORTED TO ↓
170791928451000529 28.10.2019 27.10.2020 RGI-BOI Swastha BIMA
170792028451000596 28.10.2020 27.10.2021 RGI-BOI Swastha BIMA

21.The OPS have suggested allegations of Fraud that the Complainant

intentionally failed to disclose his medical history of hypertension.
However, the Complainant has submitted that he had disclosed his medical
 9 C-25/23

history to the agent at the time of porting his policy. The agent had
reportedly assured him that his pre-existing conditions would be covered as
per the continuity benefits of the previous policy.

22.It is well-established in insurance law that non-disclosure must be both

material and intentional for the insurer to repudiate a claim. The
Complainant acted in good faith by informing the OPS and submitting all
required documentation. The subsequent cancellation of the policy
exacerbates the injustice, as it unfairly deprived the Complainant of his
health coverage at a critical time. The OPS have failed to demonstrate how
hypertension specifically impacts the surgical procedures or the claim for
cataract surgery. Moreover, the OPS did not raise any objection at the time
of policy renewal, despite the Complainant's long-standing history of
paying premiums regularly since 2011. In the absence of evidence of any
fraudulent intention on the part of the Complainant, and given his disclosure
to the insurance agent, the allegation of material non-disclosure does not
stand. Furthermore, as the Complainant did not hide his medical condition
as per communications placed on record and willingly shared his test results
with the insurance agent, the argument of fraud or suppression of material
facts holds no merit.

23.This case illustrates the significant consequences of claim denials on senior

citizens who have consistently paid premiums, relying on their health
insurance for support during medical needs. Many seniors may not fully
understand policy intricacies or the necessity of disclosing unrelated
medical conditions, leading to unintentional non-disclosures. Sudden claim
rejections can impose financial strain and emotional distress, particularly
when policy terminations expose individuals to high medical costs and limit
their options for alternative coverage due to age and medical history. The
insurer's arbitrary denial of claims undermines trust in the insurance system
and leaves seniors financially unsupported after years of premium
payments. In this context, the insurer has not acknowledged the
vulnerabilities of the Senior Citizen Complainant, warranting compensation
for the mental anguish and inconvenience caused.
 10 C-25/23

24.On 24/04/2023 the Complainant had also relied on Reliance Life Insurance
Co. Ltd. & Anr. vs. Tarun Kumar Sudhir Halder (decided on 31/05/2019),
where the Hon‟ble National Consumer Disputes Redressal Commission
(NCDRC) dismissed Reliance Life Insurance's revision petition. The
petition challenged the State Commission's order awarding compensation to
the Complainant for a repudiated insurance claim. The insured, Smt. Rekha
Halder, had died due to diabetic ketoacidosis, and the insurance company
had rejected the claim on the grounds of non-disclosure of diabetes.
However, the NCDRC held that there was no evidence to prove intentional
non-disclosure of the condition. The Commission further observed that
diabetes, being a common lifestyle disease, cannot be the sole reason to
deny insurance claims unless material facts were deliberately suppressed.

25.Biman Krishna Bose v. United India Insurance Co., 2001 (2) CPR 111 :
(2001) 3 CPJ 10 : (2001) 6 SCC 477 : (2001) 107 Comp Cas 14 / United
India Insurance Co. Ltd. v. Biman Krishna Bose, 1995 (II) CPJ 62 : (1995)
3 CTJ 319 (NC) was a case where the fact of illness (hypertension) was not
disclosed and the insurance company was guilty of delay. The
Complainant's wife fell ill and was admitted in a nursing home when the
policy was in force. A sum of Rs.8,243/- was incurred towards medical
expenses. The claim filed with the Insurance Company was not honoured in
spite of repeated reminders. The Complainant filed a complaint before the
District Forum. The Insurance Company contended that the Complainant
had suppressed material facts while taking the policy and thus the policy
was void ab-initio. Upon perusal of records the District Forum found that
the Complainant‟s wife was suffering from hypertension for five years but
the said fact was not disclosed in the proposal form. Relying upon the term
under the policy that any incorrect or untrue statement may disentitle the
insured from the benefit of the policy, the State Commission allowed the
appeal filed by the Complainant holding that non-disclosure of hypertension
would not amount to suppression of material fact and temporary or casual
suffering of hypertension not being permanent disease need not be required
to be disclosed nor was it fatal for the acceptance of the Insurance
Company. In Revision, the National Commission observed that the above
said view of the State Commission was not right. The order of the State
Commission was set aside and the order of the District Forum was restored.
 11 C-25/23

Aggrieved, an appeal was filed before the Hon'ble Supreme Court. On

10/05/1995 The Hon‟ble Supreme Court allowed the appeal with costs
which was quantified at Rs.20,000/- after subsequently setting aside the
order of the National Commission stating deficiency of service.
In Biman Krishna Bose v. United India Insurance Co. Ltd. before the
Hon‟ble Supreme Court [(26 (2001) 6 SCC 477) Judgement dated
02/08/2001], Mediclaim policy, was later not renewed by the insurance
company due to the appellant‟s prior litigation regarding a claim. The
appellant challenged this in the Calcutta High Court, which ruled in his
favor but directed him to take a new policy, as renewal with retrospective
effect was not possible. On appeal the Hon‟ble Supreme Court held that.
“5. A renewal of an insurance policy means repetition of the original policy. When renewed,
the policy is extended and the renewed policy in identical terms from a different date of its
expiration comes into force. In common parlance, by renewal, the old policy is revived and it
is sort of a substitution of obligations under the old policy unless such policy provides
otherwise. It may be that on renewal, a new contract comes into being, but the said contract
is on the same terms and conditions as that of the original policy. Where an insurance
company which has exclusive privilege to carry on insurance business has refused to renew
the mediclaim policy of an insured on extraneous and irrelevant considerations, any disease
which an insured had contacted during the period when the policy was not renewed, such
disease cannot be covered under a fresh insurance policy in view of the exclusion clause.
The exclusion clause rovides that the pre-existing diseases would not be covered under the
fresh insurance policy. If we take the view that the mediclaim policy cannot be renewed with
retrospective effect, it would give handle to the Insurance Company to refuse the renewal of
the policy on extraneous consideration thereby deprive the claim of the insured for treatment
of diseases which have appeared during the relevant time and further deprive the insured for
all time to come to cover those diseases under an insurance policy by virtue of the exclusion
clause. This being the disastrous effect of wrongful refusal of renewal of the insurance
policy, the mischief and harm done to the insured must be remedied. We are, therefore, of
the view that once it is found that the act of an insurance company was arbitrary in refusing
to renew the policy, the policy is required to be renewed with effect from the date when it fell
due for its renewal.
Learned counsel appearing for the insurance company argued that since the appellant has
not deposited the premium for subsequent years, the policy cannot be renewed with
retrospective effect. It is not disputed that the appellant sent a cheque for Rs.1,796/- towards
premium but the same was returned to the appellant. Thereafter, the parties had been
litigating and respondent insurance company stopped having any correspondence with the
appellant. Therefore, there arose no occasion for the appellant to deposit the premium. We
accordingly reject the argument of the learned counsel for the respondent. For the aforesaid
reasons, we are of the view that the High Court committed error in directing the appellant to
take fresh medicalim policy even after setting aside the order of refusal to renew the
mediclaim policy by the insurance company. The order passed by the High Court to that
 12 C-25/23

extent is not sustainable in law. We, therefore, set aside the order of the High Court to the
extent it directed the appellant to take a fresh mediclaim policy. We, further direct that if the
appellant applies for renewal of his mediclaim policy for the expired period and pays the
premium, the respondent company shall renew the said mediclaim policy forthwith."
Therefore, based on the facts and circumstances, suppression of trivial facts
such as hypertension does not affect validity of the policy.

26.In a series of judgments, the courts have consistently emphasized that

insurance companies bear the onus of proving suppression of material facts
when repudiating claims based on alleged non-disclosure. In New India
Assurance Co. Ltd. v. Lalit M. Bhambani [(2002) I CPJ 23 (NCDRC)], the
National Commission ruled that the insurer's claim of non-disclosure of
diabetes and hypertension was unsupported by evidence, and the
policyholder‟s ailment, which surfaced 15-16 months post-policy issuance,
did not indicate imminent health concerns at the time of policy inception.
Similarly, in S.B. Girijamba v. The Senior Divisional Manager,Life
Insurance Corporation of India [I (1996) CPJ 224], it was held that the
insured‟s failure to disclose diabetes had no direct nexus with the cause of
death, which was a heart attack, thus not amounting to suppression of
material facts. In Divisional Manager, L.I.C. of India v. Sushila Agarwalla
[103 (2007) C.L.T. (C.D.C.) 17 at p. 24], it was determined that even if the
insured had concealed a prior illness (diabetic mellitus and hypertension),
the insurer‟s repudiation of the claim was unjust as no fraud or suppression
was proven. Furthermore, in National Insurance Co. Ltd. v. V.L. Jain
[2014(3) CPR 760 NCDRC Revision Petition No.2648 of 2008 Date of
Judgement: 26.08.2014], the National Commission clarified that
hypertension, while a risk factor for coronary artery disease, does not
automatically absolve insurers from liability unless there is clear evidence
linking it to the onset of the ailment. The hospitalization was for treatment
of coronary artery disease and not for hypertension. In Satish Chander
Madan v. Bajaj Allianz General Insurance Co. [2016 (1) CPJ 613 (NC)]
reiterated that hypertension is a common ailment manageable through
medication, and its presence does not necessitate a heart attack or justify
claim repudiation. Lastly, New India Assurance Co. Ltd. v. Rakesh Kumar
[III (2014) CPJ 340; 2014(3) CPR 289 NCDRC Revision Petition No.2157
of 2014 & Date of Judgement: 01.07.2014] reaffirmed that mere
presumptions of pre-existing conditions (Hypertension) link without
 13 C-25/23

substantive proof are insufficient grounds for repudiation. Across these

cases, it is well established that insurers must substantiate claims of
suppression with clear and convincing evidence. Trivial or unrelated
conditions, such as hypertension, cannot serve as grounds for repudiating
legitimate claims, particularly where the procedure in question, such as
cataract surgery, bears no direct relation to the condition cited.

27.In light of the above findings, it is concluded that the Complainant's claims
for reimbursement of the cataract surgeries were wrongfully repudiated, and
the cancellation of the insurance policy was unjustified. Therefore, it would
be right for the OPS to pay the insurance claim with 7% p.a. interest from
the date of the surgeries. The Complainant was compelled to seek redress
from this Commission by filing a complaint. It is reasonable to infer that the
Complainant has endured considerable mental stress and financial loss due
to the actions of the OPS. Considering the advanced age of the Complainant
and the mental stress caused by the rejection of his claims and cancellation
of his policy, the OPS actions have caused undue hardship. While precise
quantification of compensation is challenging, Rs.2,00,000/- claim for
compensation appears excessive and is dismissed as the interest component
has been considered for both surgeries. Additionally, a sum of Rs.5,000/-
(Rupees five thousand only) is deemed reasonable towards the costs of the
complaint. Accordingly, the following reliefs are awarded:

ORDER

(a) The Complaint is partly allowed with the following reliefs:

(b) The OPS are directed to promptly pay a sum of Rs.40,000/- (Rupees
Forty Thousand only) with interest @ 7% p.a. from the date of the
right eye surgery i.e., from 04/02/2021 till the date of payment.
(c) The OPS are directed to promptly pay a sum of Rs.40,000/- (Rupees
Forty Thousand only) with interest @ 7% p.a. from the date of the left
eye surgery i.e., from 18/03/2021 till the date of payment.
(d) The OPS are further directed to reinstate the Complainant's health
insurance policy upon payment of premium, maintaining
continuity benefits.
 14 C-25/23

(e) The OPs are directed to promptly pay a sum of Rs. 5,000/- (Rupees
five thousand only) towards the costs of the complaint to the
Complainant, and if the same is not paid promptly after the appeal
period, it will incur interest at a rate of 7% per annum until payment is
made.

Pronounced in open Court. Proceedings closed.

(Shri Sanjay Motiram Chodankar)

President

(Mr. Jayson Rodrigues)

Member
yk
25/09/24