Summary
The insurer could not rely on an alleged non-disclosure to refuse renewal after accepting the final decision rejecting that same ground for repudiation of the earlier treatment claims. It had also retained the renewal premiums. The Court restored the renewal directions and ordered payment of the treatment expenses claimed under the renewed policies.
Issues
- Whether an insurer could refuse renewal on the same non-disclosure ground already rejected by a final claims decision it had accepted.
- Whether treatment claims under the policies renewed pursuant to consumer-forum orders were payable.
Provisions considered
- Health-insurance renewal clause, Insurance Regulatory and Development Authority renewal guidelines, 31 March 2009The clause required ordinary renewability, prohibited arbitrary refusal and refusal merely because earlier claims were made, while recognising grounds such as fraud or misrepresentation. The insurer could not invoke the previously rejected non-disclosure ground on these facts. (¶¶ 25, 26, 28)
Held
- The earlier direction reimbursing treatment expenses for 2007–09 had become final and had been accepted and paid by the insurer. The non-disclosed rheumatic heart disease was unrelated to the ovarian cancer for which treatment was claimed. In that litigation setting, the insurer could not revive the same rejected ground to deny subsequent renewal. (¶¶ 24, 25, 26, 28)
- The insurer had renewed the policies after the National Commission’s interim order, charged renewal premiums and never refunded them even after the later adverse renewal decision. The premiums for the disputed period therefore remained paid. (¶¶ 16, 17, 27)
- Decisions upholding repudiation for material concealment did not govern this dispute, because the earlier repudiation here had already been set aside and that result accepted by the insurer. The ruling turned on that established history rather than a general exemption from truthful insurance disclosures. (¶¶ 26, 28)
- The renewal orders of the District Forum and State Commission were restored. With valid policies covering the disputed period, the claimed treatment expenses were payable; the National Commission’s contrary common order was set aside without costs. (¶ 29)
Result
Appeals allowed; National Commission order set aside. District Forum and State Commission renewal directions restored and reimbursement of the claimed treatment expenses ordered. No order as to costs.