Returning to the facts of the present case, the strict and actual interpretation of Clause 4 reflects that the Insurance Company is permitted to exclude the expenses borne in case the insured person is suffering from any kind of Pre-existing disease(s) until the insured person is continuously covered under the policy for a minimum period of 48 months. What constitutes Pre-existing disease has been provided in the Insurance Policy itself, which reads as follows:-
“Pre-existing condition/disease definition- any condition, ailment, or injury or related condition for which insured person had signs and symptoms and / or were received medical advice/treatment 48 months prior to his/her Super Top Up Medicare policy with the company”
15. The aforesaid definition clause makes it abundantly clear that in order for a disease to be categorized as pre-existing disease, the Insured must have received medical advice/treatment 48 months prior to purchasing the policy for that particular disease. Whereas, the facts are crystal clear that the prior disease on which the Insurance Company has relied to repudiate the claim of the Insured, was last treated in the year 2004 i.e. 5 years before the Policy No. 2 was purchased. Hence, it cannot be said that the case of the Insured fulfils the essentials of the Pre-Existing disease provided in the Insurance policy.
IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION
FIRST APPEAL NO. 161/2016
IN THE MATTER OF
UNITED INDIA INSURANCE COMPANY LTD. Vs
MANMOHAN SINGH
CORAM:
HON’BLE DR. JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)
HON’BLE SH. ANIL SRIVASTAVA, (MEMBER)
PER: HON’BLE DR. JUSTICE SANGITA DHINGRA SEHGAL,
PRESIDENT
JUDGMENT PRONOUNCED ON: 02.08.2021
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