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Illness recurring after a long gap cannot be the reason for rejecting claim

In  VIPIN GROVER & ANR. Vs NEW INDIA ASSURANCE CO. LTD., the insurance company rejected a claim as the claimant had suffered the same illness 17 years back.

The NCDRC decided that the main controversy in this case is ‘whether the repudiation under clause 4.1 of the policy excludes all diseases/injuries which are from pre-existing disease when the cover incepts for the first time?  It is an admitted fact that the complainant underwent CABG in 1990 and it was brought to the notice of the OP at the time of filling of proposal form.  Thereafter, for more than 16 years, the insured had no cardiac complaints.  In our view, the disease was treated completely and the patient was under medication. The patient remained active for more than 16 years.  It appears that the OP had relied upon preponderance of probability that the persons who underwent CABG are prone for the recurrence.   Even as per clause 15, already four years waiting period was over from commencement of policy.  In 2007, he underwent angiography and angioplasty at Batra Hospital.  Therefore, in our view, the present treatment of coronary PTCA was not a consequence of any pre-existing disease.  It was neither late effect of previous cardiac ailment nor was there any pre-existing condition for which the patient needed angioplasty.

We are rather surprised that the insurance company tried all means to repudiate the claim on one or the other ground.  The OP failed to prove that the present treatment was due to the pre-existing disease.  It should be borne in mind that every human suffers trivial or minor health problems during his life span.  In the medical science, any major disease is a complex pathophysiological phenomenon having co-relation with other minor diseases also.   Therefore, if the insurance companies co-relate each and every disease with pre-existing condition, under such circumstances, the insured i.e. helpless consumers will never succeed to get his genuine claim from the insurance company.  For example, if one suffers Tuberculosis (TB) in childhood, gets cured completely by the radical Anti-koch’s treatment for 9 months; then, if he develops meningitis in his adulthood after span of 10 to 20 years, it shall not be construed as it was due to pre-existing disease.  Therefore, in our view, the OP had repudiated the claim on wrong premise, which is unjustifiable.

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