Insurance – Mediclaim policy – Pre existing disease  – Non-disclosure – Burden of  proof – Prescription – Mere mentioning in the prescription would not amount to establishing a concealment – Senior Citizens policy – Pre-medical check-up – Having opted to waive of was thus conscious – Insurer liable. [PLRonline # 446681]

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Summary

Mediclaim Policy and Pre-existing Diseases

• Burden of Proof on insurance Company: The insurance company must prove non-disclosure of a pre-existing condition by the policyholder. Mere suspicion is insufficient to repudiate a claim without concrete evidence.
• Evidence in Medical Prescriptions: A doctor's note mentioning a past complaint does not necessarily prove concealment of a pre-existing condition by the policyholder.
• Heart Disease Specifics: There's no evidence that the claimant knowingly concealed a heart condition. The onset of heart disease can be sudden and unknown to the insured, and mere inquiry about symptoms does not imply awareness of a pre-existing condition.

Senior Citizens Policy

• Awareness of Risks by Insurance Companies: Insurance companies issuing Senior Citizens Red Carpet Insurance policies are presumed aware of the associated risks, especially since these policies often have higher premiums and sometimes waive pre-medical check-ups.
• Obligation of Insurers: Insurers must demonstrate a breach of policy terms by the beneficiary. Failure to do so implies acceptance of the risk by the insurer.

Legal Services Authorities Act, 1987, Section 22D

• Role of Permanent Lok Adalat (Public Utility Services): PLA must adhere to principles of equity, fairness, natural justice, and objectivity. The High Court should not interfere with its decisions unless they are unsustainable based on evidence and proper interpretation.