IMPORTANT POINT
Every person suffers from symptoms of any disease without knowledge of same.

Prem Narain, Presiding Member—This revision petition has been filed by the complainant, Dr. Ashish Sharma, against the order dated 23.02.2012 of the Punjab State Consumer Disputes Redressal Commission, (in short ‘the State Commission’).

2. Brief facts of the case are that That Dr. M.L.Sharma father of the petitioner herein had taken medi-claim policy issued by the respondents and had been renewing the same without any break and had been paying the premium regularly. The father of the petitioner (insured) was admitted to hospital from 9.10.2005 to 15.10.2005 and expenses to the tune of Rs.1,45,829/- were incurred. On 22.10.2005 the petitioner made the claim for the expenses incurred to the respondents. The father of the petitioner (insured) expired on 29.10.2005.

3. The respondent No.1 vide its letter dated 10.01.2006 rejected the claim of the petitioner on the ground that patient is known as a case of HTN since 10 years and COPD since 15 years and his present ailment is complication of COPD. The respondents further alleged that the date of inception to medi-claim policy is 06.04.2005 so the ailment comes as pre-existing and as per terms & conditions of the policy, pre-existing ailments are not covered, hence the claim stands repudiated under clause 4.1 and same is not payable. The petitioner sent a notice to the respondent claiming the amount payable by them but the same was not replied. The petitioner filed a consumer complaint No.295 of 2006 before the District Consumer Disputes Redressal forum, Jalandhar claiming the amount spent on medical expenses of late Shri M.L.Sharma (the policy holder) along with interest, compensation for harassment and cost of litigation.

4. The respondent No.1 filed its reply to the complaint alleging that claim of the complainant is not payable in view of Exclusion Clause 4.1 of the insurance policy according to which all diseases which are pre-existing before the inception of the insurance policy are not covered under the insurance policy.

5. The District Consumer Disputes Redressal Forum, Jalandhar, after hearing the arguments allowed the complaint of the petitioner and held that insured cannot be treated having pre-existing disease at the time of the start of the last policy as he has been taking the policies continuously right from the year 1990. The District Forum, vide its order dated 13.07.2007 held that the petitioner is entitled to the claim amount of Rs.1,45,829/- along with 9% interest from the date of filing the complaint till payment and also compensation of Rs.3000/- and Rs.2000/- as cost of litigation.

6. Respondents preferred an appeal before the State Commission. The State Commission, allowed the appeal filed by the respondents and set aside the order of the District forum vide its order dated 23.02.2012.

7. Aggrieved by the order dated 23.02.2012 of the State Commission, the present revision petition has been filed by Dr. Ashish Sharma, the complainant .

8. Heard the learned counsel for both the parties and perused the documents available on the file.

9. Learned counsel for the petitioner argued that father of the petitioner was getting himself insured under mediclaim since 1990. From the year 1990 to 1993 he was insured with the United India Insurance Company, which is the current respondent No.1 and then he shifted to Oriental Insurance Company, which is respondent No.2 from the year 1994-1995. Then again he reverted back to respondent No.1 from the year 2002-2003. Thus, the father of the petitioner had continuous cover since 1990 with one insurance company or the other. The father of the petitioner was admitted to hospital from 9.10.2005 to 15.10.2005 and expenses to the tune of Rs.1,45,829/-were incurred. On 22.10.2015, the petitioner made the claim for this expense incurred to the respondents. The father of the petitioner/insured expired on 29.10.2005. The claim of the petitioner was rejected by the respondent on 10.01.2006 on the ground that patient was a known case of hypert