It was claimed that the complainant knew that she had ulcerative colitis and leukoplakia at the time of purchasing the insurance. (AI-generated image)A consumer commission in Jalandhar has directed an insurance company to reimburse Rs 72,212 spent by a Punjab woman on treatment for leukoplakia of the tongue and pay Rs 10,000 in compensation and litigation costs, holding that the insurer could not deny the claim on grounds of non-disclosure after accepting that the policy had been ported and had been renewed continuously.President Rajesh Bhatia and S Kanwar Jaswant Singh (member) were hearing a complaint filed by the woman, who sought reimbursement of Rs 72,212 spent on the treatment of leukoplakia of the tongue, a condition described in the proceedings as tongue cancer.“The commission deems it appropriate to direct the OPs (insurance company) to reimburse the insurance claim along with compensation due to mental agony and harassment suffered by the complainant at the hands of the OPs,” the June 2 order read.Also Read | Insurer fails to prove pre-existing disease led to woman’s illness, court awards Rs 10.5 lakh‘Insurance company admitted portability’The commission noted that the complainant had ported her health insurance policy from United India Insurance Company to Religare Health Insurance in 2015 and had maintained continuous coverage thereafter.The consumer body called the conduct of the insurance company tenable, finding that they sought the documents of the disease of ulcerative colitis when the complainant submitted a claim of Rs 72,212 for the treatment of the disease of leukoplakia of tongue.Noting that the first insurance policy had commenced in October 2010 and was subsequently ported to Religare in November 2015, the commission held that the claim was admissible because the insurer itself admitted the portability and continuous coverage of the policy.The commission further observed that the policy’s 48-month waiting period for pre-existing diseases had long elapsed, making the claim eligible for reimbursementHolding that there was no reason to disbelieve the complainant’s version, the commission concluded that the repudiation of the claim was illegal and unsustainable in law.Accordingly, the consumer body directed the insurer to reimburse Rs 72,212 towards the health insurance claim, pay Rs 10,000 for mental agony, harassment, and litigation expenses.Also Read | Borrower dies, insurer refunds premium instead of settling death claim: HDFC Life ordered to clear Rs 27 lakh loanPorting from one insurer to anotherIt was claimed by the complainant that she purchased a single premium health insurance policy by paying Rs 19,902 with effect from November 2019 to November 2020, which she had been purchasing since November 2015 without any break, having a sum insured of Rs 7 lakh.Subsequently, it was alleged that the complainant suffered from ulcerative colitis in 2017 and the same was treated at the medical cost of Rs 54, 658, which was duly settled by the then insurance company by reimbursing Rs 49,911 in June 107.However, it was further added that later the complainant had another health issue of leukoplakia of tongue (cancer) and she got it treated from BAPS Yogiji Maharaj Hospital, Ahmedabad, in October 2019 and paid Rs 72, 212 as medical expenses.However, it was claimed by the woman that the current insurance company in question refused to settle this mediclaim and repudiated the same on the pretext that the pre-existing disease has not been disclosed in the proposal form by the insured.Insurance company’s defenceThe counsel appearing for the insurance company, advocate Raman Kumar Sharma, argued that the complaint is not maintainable as the complainant cannot take advantage of her own wrongs.It was claimed that the complainant herself is guilty of non-disclosure of material facts at the time of taking policy, as such the complaint is liable to be dismissed.The complainant had ported the insurance policy from United India Insurance Co Ltd in 2015 and thereafter renewed it from time to time.It was highlighted that the current policy of the complainant is for the period of November 2019 to November 2020, subject to its terms and conditions.Story continues below this adIt was claimed that the complainant had knowledge that she was suffering from ulcerative colitis and had a whitish elevated lesion on the surface of the tongue (i.e., leukoplakia) at the time of purchasing insurance from the present insurance company, which was not disclosed in the proposal form and even in the medical examination form no such disclosure was made.There was neither any deficiency in service nor any negligence in service nor any unfair trade practice on the part of the insurance company, it was further mentioned.‘Unaware of lesion’The complainant’s counsel pointed out that if there had been any such doubt in the mind of the insurance company, they should have got the complainant medically examined to ensure her health status before porting the insurance.Also Read | SBI to pay Hyderabad family Rs 1.6 lakh after ‘wrongfully’ recovering dead man’s loanIt was further added that this policy was ported with the insurance company in November 2015 and was accepted by the company after due investigation and observance of the standing instructions for porting of the same.Story continues below this adThe counsel denied that her client had any knowledge about the history of a whitish elevated lesion on the surface of the tongue, being an internal development in the body.It was further argued that the present insurance company has been skilfully trying to club the bygone mediclaim of ulcerative colitis, which was settled in 2017, with the present genuine claim of leukoplakia of the tongue.It was submitted that due to a grave deficiency in service and unfair trade practice on the part of the insurance company, the complainant is entitled to all the reliefs.Richa Sahay is a Legal Correspondent for The Indian Express, where she focuses on simplifying the complexities of the Indian judicial system. A law postgraduate, she leverages her advanced legal education to bridge the gap between technical court rulings and public understanding, ensuring that readers stay informed about the rapidly evolving legal landscape. Expertise Advanced Legal Education: As a law postgraduate, Richa possesses the academic depth required to interpret intricate statutes and constitutional nuances. Her background allows her to provide more than just summaries; she offers context-driven analysis of how legal changes impact the average citizen. Specialized Beat: She operates at the intersection of law and public policy, focusing on: Judicial Updates: Providing timely reports on orders from the Supreme Court of India and various High Courts. Legal Simplification: Translating dense "legalese" into accessible, engaging narratives without sacrificing factual accuracy. Legislative Changes: Monitoring new bills, amendments, and regulatory shifts that shape Indian society. ... Read More