JAKKAMPUDI SVSKN PRA... v. AUTHORISED SIGNATORY...

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husband were covered under IBA insurance scheme for bankers since November 2015, without any break. The claim of the complainant denied till the date of annual renewal and finally denied the claim.  As the Policy facilitates certain diagnostic tests free of cost, the complainant opted for the same after 4 months.

 The complainant have undergone few more tests like USG, ECG and Mammography on payment basis.

 The complainant wife Mammography report was found to be abnormal, the complainant wife consulted a physician who referred to the oncologist who in turn advised FNAC and Biopsy of right breast.

 The complainant and his wife grief stricken when the oncologist diagnosed it as carcinoma, Later, they went through a harrowing period that too during the covid related lock down as multiple Chemos took place and every time, the complainant and his wife commuting 70-Km. A major operation of Mastectomy was carried out on 30^thJuly 2020 the chemo bills were being paid by United India as the complainant were covered under IBA insurance since 2015.

 The surgery had cost Rs.1.84 Lakh. The complainant claimed the same online, on 28.08.2020, annexing relevant documents and the same was registered by the Religare portal vide acknowledgment No. 2808202002344, Claim number 912418276. The complainant have also stated another claim for RS.450831.00 towards the chemo charges on 17.10.2020, vide claim no. 91459845.

 Later the complainant received a query in the APP, to submit Nominee's photograph and the complainant bank details, which the complainant have complied with instantly. After 6 weeks the complainant receiving the same query again and again. The complainant was surprised, but complied with the same repeatedly.

 On 28.09.2020, the complainant approached Kukatpally Office of Care Health, to submit the complainant physical claim. But

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the complainant was utterly disappointed as the staff did not receive the complainant claim stating that the front office staff are not available. They advised the complainant to send the documents to their head office. In order to save delay, the complainant had sent the claim same day by courier to Gurgaon office spending Rs.150.00.

 The complainant claim was received on 01.10.2020. The complainant reminded the insurance company by email on 06.10.2020 and 09.10.2020 but no response for the email. The complainant have requested the Opposite parties to expedite to meet the chemo expenses of Rs. 46,000.00 every 3 weeks. But No response.

 When the complainant contacted over phone, the opposite parties were told that the claim is being processed and it will take one week to 10 days. So, there is no use of online submission since physical documents are to be processed afresh!!

 The complainant sent another reminder to opposite parties on 17-10-2020 and contacted them on toll free number, they told, there is a query which needs to be replied. The complainant wrote to Opposite parties on 18^thand 19^thOctober 2020, stating that the query is only old one.

 Despite the complainant repeated enquiries, not told any paper is required. It was later found that their App was showing only the old query. They had never sent any reminder by email. At this point the complainant felt that the silence on part of the company is to wait till the complainant renewed the policy.  The due date for renewal was 23.10.2020 and the complainant renewed the policy on 22.10.2020 to maintain continuity. The company had sent 33 reminders for renewal but disclosed the requirement of additional document only on 21.10.2020 when the complainant had sent mails with subject as "Serious Matter".

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 As per mails dated 18 & 19 October, the replies were just acknowledgement, stating that the matter is referred to the concerned team.

 As per their mail dt.21.10.2020, (after 20 days of receipt of physical documents and just a day before the renewal due date) the complainant asked to submit the following:-

INVESTIGATION REPORT SUPPORT DIAGOSIS. BIOPSY,

FNAC, MAMMOGRAM, ALONG WITH ALL OTHERS.

EXACT DURATION AND PAT HISTORY OF PRESENT AILMENT

WITH 1^ST CONSULTATION PAPER AND ALL PAST

TREATMENT RECORDS. BREAST LUMP, ALONG WITH FIRST

CONSULTATION.

 When the complainant contacted opposite party official. Mr. Abhshek Singh over phone stated that everything was already submitted he told the complainant to send the biopsy report and the discharge summary of initial Chemo. The complainant submitted the same.

 The insurer had sent rejection letter to the complainant on 06.11.2020, stating that the disease is pre-existing.  The complainant represented to their grievance cell on 20.11.2020. They were unmoved for 2 months. This online complaint was followed by emails dt.14.12.2020, 4.01.2021 & 15.01.2021. They were unmoved for 2 months. This online complaint was followed by emails dt.19.01.2021 that they stick to their decision.

2. The complainant contentions as follows:-

a). The policy was taken October 2019, Mammography in conducted there was problem.

b).The complainant have strong objection their calling the lump as disease even when the doctor didn't use the term disease this or cancer. Insurer is not a qualified a doctor in the absence of any diagnosis/ treatment by medical practioner. A painless lump need not be suspected/diagnosed as carcinoma.

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For that matter. The complainant have small lumps in his arms for nearly 20 years. Moreover there is no mention of any disease in complainant wife matter Health checkup done in KMC Hospital Manguluru dt.17.05.2017. c).The complainant covered under IBA Insurance policy since November 2015. Without break.

d). Even if the complainant had an aorta of doubt that it is a disease.

i) The complainant would have started the treatment to his wife immediately without even waiting for a day, instead of leisurely availing the freebies of lab tests, that too after 4 months.

ii) The complainant would have taken a top up policy of Rs.5,00,000/- by paying as less as Rs.6,000/- while renewing IBA policy in October 2019.

e).As the SA limit Rs.4,00,000/- under IBA policy was Exhausting towards Chemo therapy the complainant tried to fall back on Religare policy for the surgery expenses.

f). Expenses of Rs.1,84,000.00/- towards surgery and Rs.45,000/- towards Chemo is use amount for retired senior citizen and his wife is a home maker whose nodes were removed from right hand during the surgery, advising her not to lift weight above 4 Kgs and to avoid any kind of burns.

e). The exclusion clause in the policy excludes the breast lump "unless it is malignant". But the biopsy reports proved that it is malignant. h). whatever mails sent by complainant were shown as bounced by Religare mail server saying the mailbox is full. However, Mr. Abhishek had at a later date confirmed receipt of all mails. The App maintended by Religare by poorly designed without proper testing. Company's mission is to assure worry free recovery without a care about medical bills and other related expenses. They have changed their name from Religare to care, but failed to take care of their clients.

g). Further the complainant stating that he have been fighting with the company through various channels during the last 3-4 years which include the period of corona for nearly 2 years. The complainant was in Australia for more than 18 months during that period, for taking care of

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his prematurely born granddaughter. Therefore the complainant filed complaint with following prayer:-

1. Payment of Rs.2,29,831.00 towards settlement of 2 claims rejected by the company. (As allowed vide order dt. 06.05.2025 in IA 32/2025)

2. Compensation of Rs. 2,00,000/- towards the mental agony suffered during the period of Corona especially due to the casual attitude of the company. 3. Further, the complainant pray for an Award of Rs.1 Lakh towards cost of litigation, advocate fee etc., 4. Any other expenditure as deemed fit by the consumer commission to curb such unfair practices of misinterpreting the facts to their advantage and pushing the gullible public towards avoidable entanglement by opposite parties, in future.

II. To the case of complainant the opposite parties No.1 & 2 filed their Written Version as under:-

3. The opposite parties stated that the opposite party is company duly incorporated under the companies Act, 1956, having its corporate office at Vipul Tech Square, Tower C 3rd Floor, Golf course road, Sector-43 Gurgaon-122 009 (Haryana) and is into business of providing Health Insurance Services.

4. The opposite parties company deny in extensor and in extremity each and every allegation/averment/contention claim/demand, made by the complainant in the compliant under reply as being made on surmises and conjectures and nothing contained herein may be construed to have been admitted by the opposite parties company unless expressly and specifically stated to be admitted herein.

Preliminary objection:-

5. The complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainants have attempted to misguide and mislead the commission.

6. The present complaint filed by the complainant is with the mala-fide intention and has not come before this Commission with the clean hand being litigation for the sake of litigations is liable to dismissed with exemplary costs.

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7. That prima facie no cause has arisen in favour of the Complainant to file the present Complaint, as the complainant claim is not fall within the Insurance as granted by the opposite party. Hence, the present complaint is liable to be dismissed with exemplary costs.

8. That intricate questions of law and facts are involved in the matter in issue and parties should have to lead evidence by examining the witnesses and the other party should have to cross examine the witnesses and the matter involved in this case cannot be decided in summary manner. The complainant, may approach the Civil Court.

9. The complaint is false, frivolous and vexatious in nature, as such the complainant is liable to pay penalty under the Act to the opposite party. The complainant is stopped from filing the present complaint by his own acts, conduct, omissions and acquiescence.

10. The complainant has tried to challenge the veracity of decision of the opposite party to repudiate the claim. The Company has repudiated the claim under the said policy by a speaking order, which lists out the specific reasons for the decision. By no stretch of imagination the said decision can be brought under the umbrella of 'Deficiency in Services'. The Complainant should approach the Civil Courts in order to challenge the veracity of the decision of the opposite party company to repudiate the claim.

11. The complainant is devoid of any material particulars, and has been filed merely to harass and gain undue advantage and unjustified monies from the Opposite Party, hence the complaint deserves to be dismissed in limine. The complaint has been filed with ulterior motive malafide intention, to cause harassment and prejudice to opposite party, which is a company of long standing and high repute, and to extract money from it without just cause or valid reason. The subject matter for the above policy itself is proved to be initiated by fraudulent act, therefore, the said policy is declared void by the opposite party, and consequently, no benefit or amount under the said policy becomes payable, as the complainant is guilty of suggest varisupressofalsi.

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12. This Commission has no jurisdiction to entertain the present complaint. The complainant has failed to demonstrate any deficiency in service on the part of the Opposite Party. Deficiency is defined under the Consumer Protection Act which means any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance; which is required to be maintained in pursuance of a contract. In the present case, the opposite party has strictly acted as per the terms and conditions of the policy contract. The terms of the policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. Thus, the words in an insurance contract must be given paramount importance and interpreted as expressed with any addition, deletion or substitution. That the Commission cannot pass any order in contravention to the terms and conditions of the policy contract. The burden of proving the deficiency in service is upon the person who alleges it. The complainant has, on facts, been found to have not established any willful fault, imperfection, shortcoming or inadequacy in the service of the opposite party. The deficiency in service has to be distinguished from the tortious acts of the opposite party. In the absence of deficiency in service the aggrieved person may have a remedy under the common law to file a suit for damages but cannot insist for grant of relief under the act for the alleged acts of commission and omission attributable to the opposite party which otherwise do not amount to deficiency in service. In case bonafide disputes no willful fault, imperfection, shortcoming or inadequacy in the quality nature and manner of performance in the service can be informed. If on facts it is found that the person or authority rendering service had taken all precautions and considered all relevant facts and circumstances in the course of the transaction and that their action or the final decision was in good faith, it cannot be said that there had been any deficiency in service. If the action of the opposite party is found to be in good faith, there is no deficiency of service entitling the aggrieved person to claim relief under the act. The rendering of deficient service has to be considered and decided in each case according to the facts of that case for which no hard and fast rule can be laid down. Inefficiency, lack of due care, absence of bona fides, rashness, haste or omission and the like may be the factors to ascertain the deficiency in rendering services.

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13. The complainant has not acted in good faith with respect to subject of this complaint and has approached the Commission with unclean hands, whereas it is settled legal proposition that "One who seeks equity must come with clean hands". The Complainant is thus not entitled to any relief from this authority and the complaint deserves to be dismissed on this count as well.

14. The insurance is a contract of utmost good faith and that the contract of insurance is base on Doctrine of Uberrima Fides and even if any due diligence is done by the insurance company, it does not change the basic element of an insurance contract.

15. The proposal form is not merely a document to be signed and submitted for formality. It is the basis for the contract of insurance. It is the mode of providing information to the insurer so as to enable them to exercise a lawful right to evaluate services by covering the life. A reference is most respectfully made here to Regulation 2(2) (d) of the IRDA (Protection of Policyholders' Interests) Regulations, 2002 which provides that "Proposal Form" means a form to be filled by the proposer for insurance, for furnishing all material information required by the insurer in respect of a risk, in order to enable the insurer to decide whether to accept or decline, to undertake the risk, and in the event of acceptance of risk, to determine the rates, terms and conditions of a cover to be granted.

16. The preliminary objections raised herein above with regard to the maintainability of the complaint, go to the very root of the matter and as such these objections need to be considered at the outset and the opposite party most humbly prays that this Authority may be pleased to dismiss the complaint summarily without going into the merits thereof.

17. The complainant has sought a relief from this Commission which he is not entitled to get under the terms and conditions of the subjected Insurance Policy and as such no deficiency in services on the part of the opposite party have been demonstrated by the Complainant. The Opposite Party Submits These are serious allegations that cannot be decided under the Consumer Protection Act. Hence the complaint deserves to be dismissed.

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18. The complainant has sought relief based on allegations not supported by any documentary evidence to substantiate them. Therefore, the complaint does not deserve any consideration from this Commission and merits dismissal at the threshold.

19. That There is no deficiency in the service rendered by the opposite party in the present case. The opposite party is not a necessary or proper party to the present dispute. Accordingly, the present complaint ought to be dismissed against the opposite party. The complaint, being frivolous and vexatious, is liable to be dismissed under the Consumer Protection Act in the light of the above, the complaint is not maintainable. Hence, the present complaint is liable to be dismissed forthwith.

Brief Facts:

20. Paragraph wise reply to the contents of the complaint, the opposite party crave leave of this court to delineate factual matrix of the case as under:-

21. The opposite party company issued a group health insurance policy to the group policyholder I.e. Corporation Bank vide Group Policy No. 14433091 namely "Group Care (Corp. Health Suraksha)"

thereby covering its customer Mr.Jakkampudi Svskn pradad and his spouse vide certificate in Insurance No. 16091738 from 24.10.2019 till 23.10.2020 for a sum insured up to Rs. 3,00,000/- subject to policy terms and conditions. The said policy was further renewed on an annual basis with the latest policy effective from 26.10.2024 till

25.10.2025.

22. Believing the information and details provided by the proposer including the medical history to be true and correct in all respect and giving due credence to the under writing norms of opposite party company. A Policy was issued. The copy of Schedule bearing relevant details of the policy along with policy bond having terms and conditions were duly sent and delivered to the proposer. Further, No assurance was given to the complainant beyond the terms and conditions of the policy.

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23. The opposite party company further submits that the policy kit containing all relevant documents was duly delivered to the complainant from time to time, thereby giving an opportunity to the complainant to verify and examined the benefits, terms and conditions of the policy taken by the complainant. The complainant never approached the opposite party company stating that any information given in the policy schedule was incorrect.

24. That reliance is placed on the judgment of Ld. National Commission in Mohan LalBenal versus ICICI Prudential Life Insurance Co. Ltd. (decided on 16.10.2012); and Harish Kumar Chadha Versus Bajaj Allianz Life Insurance Co. Ltd. (decided on 07.10.2013) wherein Ld. National Commission had clearly held that if the insured was not satisfied with the policy taken, he/she should avail the option of returning the policy within the 'Free-look Period' of 15 days from the date of receipt of the policy.

25. In case titled as Gas Ghar V/s. Oriental Ins. Co. Ltd. (2006) 3 CPPJ 377 Hon'ble National Commission held that- plea of non-receipt of policy with schedule by the petitioner cannot be accepted and dismissed the revision.

26. The Opposite party received a reimbursement claim bearing No. 91418276 for the hospitalization of the complainant's spouse (herein referred as insured) at Soumya Multi Specialty Hospital, Secunderabad from 30.07.2020 till 07.08.2020 as she was diagnosed with carcinoma right Breast. Copy of the claim form is marked as Annexure-OP2. Copy of the discharge summary marked as Annexure-

OP3.

27. That Upon the receipt of the claim few queries dated 19.09.2020, 26-09-2020 and 17.10.2020 were raised and the complainant was asked to provide following documents:

KINDLY PROVIDE

1. RECENT PASSPORT SIZE PHOTOGRAPH OF PROPOSER/NOMINEE.

MR JAKKAMPUDI SVSKN PRADAD.

2. PERSONALIZED CANCELLED CHEQUE IN THE NAME OF

PROPOSER/PRIMARY MEMBER OR NEFT MANDATE FORM

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SIGNED AND STAMPED BY BANK AUTHORITIES. MR.

JAKKAMPUDI SVSKN PRADAS.

3. INVESTIGATION REPORT SUPPORTING DIAGNOSIS.

BIOPSY, FNAC MAMMOGRAM, ALONG WITH ALL OTHERS.

4. EXACT DURATION AND PST HISTORY OF PRESENT AILMENT

WITH 1^ST CONSULTATION PAPER AND ALL PAST TREATMENT

RECORDS.

BREAST LUMP, ALONG WITH FIRST CONSULTATION.

28. Upon the receipt of the query reply its was noted that as per the discharge summary of soumya Multi specialty Hospital, Secunderabad dated 18-03-2020, patients has lump in right breath since 3 years. Copy of the Discharge summary dated 18.03.2020.

29. The said claim request was denied via denial letter dated 05.11.2020 on the following grounds:

 AS PER DISCHARGE SUMMARY OF 18/03/2020 SOUMYA

HOSPITALPATIENT HAS PRESENTING COMPLAINTS PRIOR TO

POLOCY INCEPTION HENCE CLAIM CANNOT BE CONSIDERARED

AS PER POLICY TERM AND CONDITION AS DISEASE IS PED PRE-

EXISTING DISEASES 25 MONTHS WAITING PERIOD.

 2 YEARS WAITING PERIOD.

30. That further a reimbursement claim bearing claim no. 91459845 was filed for the day care hospitalization of the complainant's spouse (herein referred as insured) at soumya Multi specialty Secunderabad on 17-10-2020 as she was diagnosed with Carcinoma right breast.

31. On the basis of the aforementioned findings the claim of the complainant was rejected via claim denial letter dated 06.11.2020 on the grounds of:

 AS PER DISCHARGE SUMMARY OF 18.03.2020 SOUMYA HOSPITAL

PATIENTS HAS PRESENTING COMPLAINTS PRIOR TO POLICY

INCEPTION HENCE CLAIM CANNOT BE CONSIDERED AS PER

POLICY TERM AND CONDITION AS DISEASE IS PED.

 2 YEAR WAITING PERIOD FOR TREATMENT OF PRE-EXISTING

DISEASE AND ITS COMPLAINANTS

32. The complainant/insured had the chance to disclose about her past medical history of carcinoma breast at the time of filling the

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proposal form, but the insured failed to disclose the same for the best reasons known to her.

33. It is pertinent to mention he that depending upon the disclosures made by the complainant at the time of proposal, the Respondent company decides whether to accept the risk and provide the policy to the customer or not. It is the duty of the insured to disclose correct and accurate information about his/her current health status at the time of proposal for the accurate assessment of risk. However, the complainant by not disclosing the correct faith i.e., Uberrimae Fides and the policy terms and conditions which is the basis of contract between the complainant and the company.

34. The relevant clause as per terms and conditions is reproduced herein below:

Clause3: EXCLUSIONS

1.1 Waiting Period

B) Specific Waiting period:

i). Any Claim for or arising out of any of the following Illnesses or Surgical Procedures shall not be admissible during the first 24 consecutive months from the Cover Start date:

I. Arthritis (if non-infective), Osteoarthritis and Osteoporosis, Gout, Rheumatism and Spinal disorders, Joint replacement Surgery;

II. Benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty), nasal septum deviation, Sinusitis and related disorders;

III. Benign Prostatic Hypertrophy;

IV. Cataract;

V. Dilatation and Curettage;

VI. Fissure / Fistula in anus, Hemorrhoids / Piles, Pilonidal Sinus, Gastric and Duodenal Ulcers;

VII. Surgery of Genito urinary system unless necessitated by malignancy;

VIII. All types of Hernia, Hydrocele;

IX. Hysterectomy for menorrhagia or fibromyoma or prolapse of uterus unless necessitated by malignancy;

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X. Internal tumors, skin tumours, cysts, nodules, polyps including breast lumps (each of any kind) unless malignant;

XI Kidney Stone/ Ureteric Stone/ Lithotripsy/ Gall bladder Stone; XII Myomectomy for fibroids;

XIII Varicose veins and varicose ulcers.

(ii) If an Insured Member is suffering from any of the above Illnesses, conditions or Pre-existing Diseases at the time of commencement of the first Cover Start Date, that Insured Member shall not be covered for any Claim in respect of or related to that Illnesses, condition or Pre-existing Disease until the completion of the period specified in the Policy Certificate but not exceeding 48 months of continuous insurance coverage with opposite party from the first cover start date under the first policy with them.

35. Further it is pertinent to mention that in the policy certificate under the schedule of benefits it has been mentioned that there is a 24 months waiting period on pre-existing disease.

36. The Insurance Regulatory and Development Authority of India (IRDAI) (Protection of Policy Holder's Interest) Regulations, 2017 under Clause 19(4) enumerating the "General Principal" casts an absolute duty to disclose all material facts to the Insurer in order to assess the risk as per its capacity. The same is reproduced herein for your reference:

"The policyholder shall furnish all information that is sought from him by the insurer either directly or through the distribution channels which the insurer considers as having a bearing on the risk to enable the insurer to assess properly the risk covered under a proposal for insurance."Thus the complainant herein is not only acting in breach of the Policy Terms and Conditions governing the policy, but also has acted in blatant violation of the above stated Regulations.

37. In the following judgments, the Hon'ble Courts have held that both the parties are bound by the terms and conditions of the policy:

38. The Export Credit Guarantee Corpn of India Ltd. Versus M/s Garg Sons International pronounced by the Supreme Court of India that:

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39. "11. The insured cannot claim anything more than what is covered by the insurance policy."...the terms of the contract have to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely." Consequently, the clauses of an insurance policy have to be read as they are... Consequently, the terms of the insurance policy that fix the responsibility of the Insurance Company must also be read strictly. The contract must be read as a whole and every attempt should be made to harmonize the terms thereof, keeping in mind that the rule of contra proferentem does not apply in case of commercial contracts, for the reason that a clause in a commercial contract is bilateral and has mutually been agreed upon. (Vide: Oriental Insurance Co. Ltd. v. Sony Cheriyan . AIR 1999 SC 3252; Polymat India P. Ltd. v. National Insurance Co. Ltd., AIR 2005 SC 286; M/s. Sumitomo Heavy Industries Ltd. v. Oil & Natural Gas Company, AIR 2010 SC 3400;

and RashtriyaIspat Nigam Ltd. v. M/s. Dewan Chand Ram Saran

AIR 2012 SC 2829).

40. It has been held by Hon'ble Supreme court in the matter of United India Insurance company ltd. Vs HarchandRAiChandanLal {(2004) 8 SCC 644} as: ' It is settled law that terms of the policy shall govern the contract between the parties, they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of policy and not with reference to the definition given in other laws. It is a matter of contract and in terms of the contract, the relation of the parties shall abide and it is presumed that when the parties have entered into a contract of insurance with their eyes wide open, they cannot rely on definition given in other enactment".

41. That in the light of above the complaint is not at all maintainable since the complainant himself violated the terms and conditions of the policy and there is no deficiency in services on part of opposite party and hence the present complaint is liable to dismissed forthwith.

42. It is pertinent to mention here that the claims are paid by any Insurance Company out of the common pool of funds belonging to all policyholders of the Company, which makes it obligatory upon the

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Insurance Company to check the genuineness and admissibility of each claim before honoring it in the larger interest of all the policy holders. The Insurance Company cannot do injustice to genuine policyholders by allowing inadmissible claims.

43. The opposite party is a registered Health Insurance Company under the Insurance Law and provides its benefits as per rules and regulations of insurance Law. The opposite party provides benefits of the policy as per terminology of the policy and never assured to any its policyholder to provide benefits beyond its terms and conditions.

44. The opposite party does their work as per policy terms and conditions and further as per the law laid down by the Apex Court by delivered various judgments held that both parties are bound with the policy terms and conditions. It is specifically mentioned here that the replying opposite party followed the entire rules and regulations framed by the IRDA and further the terms and conditions also passed by IRDA which is a statutory body under the act. Moreover as per law laid down by Apex Court in Constitution Bench judgment titled as General Assurance Society Ltd. Versus Chandmull Jain & Others stated that In interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties because it is not for the court to make a new contract, however reasonable, if the parties have not made it themselves. The Apex Court in another judgment delivered titled as Life Insurance Corporation Limited & Others Versus Smt. S. Sindhu decided on 04/05/2006 stated that Moreover, the courts and Tribunals cannot rewrite contracts and direct payment contrary to the terms of the contract, that to the defaulting party. Be that as it may. Further, the Apex Court has also taken the same view in Judgment titled as United India Insurance Co. Ltd. Versus M/s Harchand Rai ChandanLal and in Judgment titled as Suraj Mal Ram Niwas Oil Mills Versus United India Insurance Co. Ltd. The Opposite party provides its best services to its entire policy holder so there is no deficiency on the part of the replying opposite party. The opposite party never indulged into any unfair trade practice rather provides its best services as per terms and conditions. The complainant has not suffered any mental tension, harassment, agony, due to the act and

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conduct of the opposite party rather the complainant herself violated the terms and conditions of the policy.

45. No cause of action was ever been arisen in favour of the complainant against the opposite party rather if any cause of action has been arisen i.e. only in favour of the opposite party against the complainant due to involve them into an uncalled litigation, so the complainant is liable to be penalized as per the provisions of CP Act and also liable to pay costs of litigation to the replying opposite party. The Insurance is a contract between the insured and insurer, so the provisions of the Insurance Act, 1938, IRDA Act, 1999 rules and regulations must be applied in the case in hand. Moreover, the insurance policy is governed by its terms and conditions and that are also applied on the facts of the case. The complainant does not fall within the definition of a consumer so this Commission has no jurisdiction to entertain and try the present complaint and the complaint is liable to be dismissed.

46. The Complainant has failed to make out a prima facie case and cause of action against the opposite party. Hence, for the reasons stated above, the reliefs sought for by the complainant in his complaint are denied as false, unsustainable, and without any merits, and the complainant be put to strict proof of the same. The complainant has no ad-judicable grievance against the opposite party in the complaint against the opposite party and therefore, failed to prove any cause of action are prima facie in the complainant against opposite party therefore failed to set up any reliefs as prayed by complainant. Hence prayed for dismissed the complaint.

II. Evidence Affidavit of the Complainant :-

47. The Complainant filed his evidence affidavit as PW-1 on 09-01- 2025 and additional affidavit also filed on 18.06.2025. The exhibits Ex-A1 to Ex-A23 are marked on behalf complainant.

IV. Evidence Affidavit of the Opposite parties:1& 2:-

48. The Opposite parties No.1 & 2 filed their evidence affidavit as RW-1 on 18.03.2025 and got marked their documents as exhibits Ex.B1 to Ex.B11.

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49. The complainant filed a memo on 04.04.2025 stated that the evidence affidavit treat as written arguments and Oral arguments of both parites on 24.07.2025.

VI. Now the points for consideration are:-

a) Whether there is any deficiency of service/unfair trade practice on the Part of the Opposite parties?

b) Whether the complainant is entitled for the relief claimed?

c) If so, to what relief?

V. Points No. (a) and (b):-

50. There is no dispute that the complainant obtained health insurance policy from the opposite parties to protect him and his wife under senior citizen care with vide bearing policy No.16091738, which is covered from 20.10.2019 to 19-10-2020. There is no dispute on medical diagnostics conducted by LUCID medical diagnostics private limited. It proves that the complainants wife suffering with malignancy. Which is marked as Ex.A8.Further there no dispute that the complainant incurred on amount of Rs.2,29,831/- (As per order IA.No.32 of 2025) towards mastectomy conducted on 30.07.2020 at Soumya Multi Specialty Hospital at Secunderabad.

51. Only dispute between the complainant and opposite parties is that the complainant's wife is suffering with pre-existing disease. Therefore the Opposite parties stated that the complainant is not entitled for treatment amount incurred to his wife from the opposite parties.

52. As per Ex.A6through intermediary of corporation Bank the complainant obtained (Corp Health Suraksha)Policy by paying premium of Rs10856/-with vide group policy No14433191 with certificate of insurance No.16091738 which covers from 24 October 2019 to midnight 23 Oct 2020for cover sum of Rs.3,00,000/-for medical expenses from Opposite parties.

53. The complainant and his wife are covered under IBA insurance policy without break since November 2015.As per exhibit A5dated 17.05.2017 at page 3 while the IBA policy was in force both wife and

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husband were under gone health check at KMC Hospital Manguluru. Which does not revels the complainant's wife suffering with carcinoma cancer.

54. This Commission reiterate the averments of complaint that "the complainant have small lump in his arms for nearly 20 year moreover there is no mention of any disease in his wife's master health checkup done in KMC hospitals Manguluru on 17.05.2017. Further the averments also discloses if the complainant's wife had on aorta of doubt that it is a disease, they would have started the treatment immediately without even waiting for a day. This Commission also under the opinion if any ordinary human being will not wait for a day for treatment till insurance amount receives.

55. As per Ex.A8 shows that after issuing the policy the mammography both breasts (CC & MLO views) conducted on 04.02.2020. Which confirm the carcinoma cancer to the complainant's wife. The claim of the complainant was rejected by the Opposite parties on the Ground of Non-discloser of pre-existing disease. Here this commission observed that prior to receive the medical reports from hospital authorities the opposite parties issued policy to the complainant. If the opposite parties suspected the health condition of complainant wife they would have to wait till the Medical reports received from complainant. But it is not happened in the present case. So the opposite parties held responsible for medical bills incurred by complainant toward treatment of his wife.

56. But on report by LUCID diagnostics on 04.02.2020 took treatment in Soumya Multi Specialty Hospital. When the matter is reopen and legal aspects on 29.07.2025 the complainant filed a memo along with Email received from insurance Ombudsman with utilization medical bills for Rs.3,99,798/- from previous insurance company i.e., IBA insurance sum insured under IBA is only Rs.4,00,000/- after utilizing the treatment amount from 04.03.2020 to up to major operation of Mastectomy carried out on 30.07.2019. Only balance of Rs.202/- is lift over in IBA insurance policy. Therefore it deems that after exhausting the Insurance covered amount from IBA the complainant approached Religare Insurance Company for further treatment amount spent by the complainant i.e for Rs.2,29,831/-.

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57. Breast carcinoma and operation of the wife of complainant was done on 20.02.2020.After the lapse of 4 months from the date of obtaining of Insurance policy from Religare Insurance Company.

58. It would be wrong to say that the material fact has been concealed, Non-disclosed by the complainant as before report of biopsy, they has never either indicated or knowing about the disease of cancer. The cancer growth was detected for the first time vide biopsy report dated 04.02.2020 i.e., after the lapse of around Four months from the date of medical Insurance policy issued by Religare Insurance Company. The said report indicated breast carcinoma which is a type of breast cancer.

59. The complainant and his wife had no prior exclusive knowledge of the disease. Hence, they are not obligated to disclose the same as held in the case of Life Insurance corporation of the India and Verses V.Ashagoel (2001) 2 SCC .Every normal prudent human being would want to enhance medial insurance coverage so as to avail better medial infrastructure and facilities to safe grant there future.

60. We also deem it appropriate to refer the National commission case titled Praveen Damani vs. Oriental Insurance company limited, reported at 2006 (3) CPR 295, wherein it has been held as under:-

61. "Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because in Insurance company relies on their clause 3.1Bx of the policy in a malafide manner to repudiate all the claims. No claim is payable under the medical policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this so every person should do medical studies and further not take any insurance policy".

62. The Opposite parties stated that claim request was denial through letter on 05.11.2020 which is marked as Ex.B6 and Ex.A13.

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As per that letter and averments of written version reveals that "AS PER DISCHARGE SUMMARY 18/03/2020 of SOUMARY

HOSPITALPATIENT HAS PRESENTING COMPLAINTS PRIOR TO

POLICY INCEPTION HENCE CLAIM CANNOT BE CONSIDERED AS

PER POLICY TERM AND CONDITION AS DIEASE IS PED. PRE-

EXISTING DESEASES 24 MONTHS WAITING PERIOD I.E., 2

YEARS". But the policy Exclusion clause says the internal tumors, skin tumors, cysts, nodules, polyps including breast lumps (each of any kind)unless malignant find a mention in the said clause since clause excludes tumor of breast unless malignant. But the biopsy reports proved that it is malignant. As per Ex.A11 lump in right breast since in 3 years. Increasing in size since 3 months painless. Hence it is clear that the wife of complainant suffering with cancer since 4 months only. Therefore this is not pre-exiting disease. Expect the above evidence the opposite parties not adduce cogent evidence before this commission to show that the wife of complainant suffering with carcinoma cancer since long back. The decision of insurance company in rejecting the claim is not proper. As such malignant tumors of breast are outside the exclusion clause of 24 months waiting period therefore the insurance company is directed to make the payment as per terms and conditions in respect of treatment took by complainant's wife and the claim filed by complainant.

63. All the Medical expense bills are submitted by the complainant along with complaint and the said Medical bills are not disputed by the Opposite parties in their written version. Hence the same is deemed to be admitted.

64. Therefore, in view of the above discussion of the case, we are of the considered opinion that there is deficiency in service and unfair trade practice on the part of the opposite parties towards complainant. Thus the opposite parties are hereby directed to reimburse the medical bill amount ofRs.2,29,000/- (Rupees Two Lakhs Twenty-Nine Thousand Only) spent by the complainant for treatment of his wife along with interest @ 6% per annum from the date of the complaint i.e., 23.10.2024 to till it's realization to the complainant. The Complainant is also entitled towards compensation for the mental agony and trauma and also the costs of the present proceedings. The points No. (a) and (b) are answered accordingly.

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VI). In the result under Point (c):- the Complaint of the complainant is partly allowed, and we direct the Opposite Parties No.1 &2 jointly and severally:-

i) To reimburse the medical bill amount of Rs.2,29,000/- (Rupees Two Lakhs Twenty-Nine Thousand Only) spent by the complainant for treatment of his wife along with interest @ 6% interest per annum from the date of Complaint i.e., 23.10.2024 to till it's realization to the complainant.

ii) To pay an amount of Rs.5,000/- (Rupees Five Thousand Only)

towards compensation for the mental agony and trauma undergone by the complainant.

iii) To pay an amount of Rs.5,000/- (Rupees Five Thousand Only)

towards the costs of the Litigation.; Time for compliance is (45) days from the date of receipt of copy of this order;

Typed to my dictation by Stenographer on the System corrected by me and pronounced by us in the open court on this the 18^th day of September, 2025.

Sd/- Sd/- Sd/-

MEMBER MEMBER PRESIDENT

APPENDIX OF EVIDENCE

WITNESSES EXAMINED

For Complainant:- For Opposite Parties PW.1:-JakkampudiSvskn Prasad S/O Late Dubaraju,

(Affidavit filed)

RW.1:-Prabhjyot Singh

Authorized Signatory of Care Health Insurance Limited,

(Affidavit filed)

DOCUMENTS MARKED

For Complainant:-

Ex.A1/dt.10.02.2020 - Copy of Insurance Regulatory and Development Authority of India.

Ex.A2/dt.21.09.2019 - Copy of Human Resource Management-Personnel Admn. Division.

Ex.A3/dt.04.12.2019 - Copy of Group Medical Insurance Policy- Corporation Bank Retiree Employees.

Ex.A4/dt.17.08.2016 - Copy of health insurance policy. dt. 16.08.2017

Ex.A5/dt.Nill -Copy of Personal details.

Ex.A6/dt.24.10.2019 -Copy of Religare certificate of Insurance. Ex.A7/dt.29.10.2019 - Copy of Premium Acknowledgment. Ex.A8/dt.04.02.2020 - Copy of Mammography of both Breasts.

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Ex.A9/dt.30.07.2020 - Copy of Bill for hospitalization. Ex.A10/dt.27.09.2020 - Copy of Final Bill. Ex.A11/dt.18.03.2020 - Copy of discharge Summary. Ex.A12/dt.17.10.2020 - Copy of Deficiency Letter. Ex.A13/dt.05.11.2020 - Copy of Claim Denial Letter. Ex.A14/dt.06.11.2020 - Copy of Claim denial letter. Ex.A15/dt.07.05.2022 - Copy of email message. Ex.A16/dt.27.07.2023 - Copy of by Registered post with acknowledgement Due card.

Ex.A17/dt.27.07.2023 - Copy of Legal Notice.

Ex.A18/dt.Nill - Copy of passport showing visa stamping. Ex.A19/dt.21.12.2021 - Copy of NSW Health westem Sydney Local health District.

Ex.A20/dt.Nill - Copy of Excerots.

Ex.A21/dt.Nill - Copy of Proceedings before the insurance OMBUDSMAN Pune.

Ex.A22/dt.Nill - Copy of Passport as address proof. Ex.A23/dt.17.10.2020 - Copy of Soumya Multi Special Hospital Final Bill.

For Opposite parties:-

Ex.B1/dt.24.10.2019 - Copy of Care health Insurance. Ex.B2/dt.04.02.2020 - Copy of the Hospitalization. Ex.B3/dt.30.07.2020 - Copy Discharge Summary.

Ex.B4/dt.26.09.2020 -Copy of Deficiency letter.

Ex.B5/dt.18.03.2020 - Copy of Soumya multi-specialty Hospital. Ex.B6/dt.05.11.2020 - Copy of Claim denial letter. Ex.B7/dt.01.10.2015 - Copy of Religare Health Insurance. Ex.B8/dt.17.10.2020 - Copy of Soumya multi-specialty Hospital. Ex.B9/dt.06.11.2020 - Copy of Claim denial letter. Ex.B10/dt.Nill - Copy of Health Questions.

Ex.B11/dt.Nill - Copy of Policy Terms and Conditions. Sd/- Sd/- Sd/-

MEMBER MEMBER PRESIDENT