The central legal point established in the judgment is the obligation of the insurance company to prove pre-existing diseases of the insured, the application of exclusion clauses, and the principles of natural justice in consumer protection cases.

ORDER :

P.S. Rana, President—Present appeal is filed under Section 15 of Consumer Protection Act, 1986 against order dated 30.11.2017 passed by learned District Forum in consumer complaint No. 60/2017 titled Kamal Kishore Mahajan v. Oriental Insurance Company Ltd.

Brief facts of consumer complaint:

2. Shri Kamal Kishore filed consumer complaint under Section 12 of Consumer Protection Act, 1986 pleaded therein that complainant purchased PNB-Oriental Royal Mediclaim Policy No. 263201/48/2013/3333 from opposite party on dated 13.3.2013 and mediclaim policy was further renewed from time-to-time till 12.3.2016. It is pleaded that complainant has regularly paid the premium to opposite party till March 2016. It is pleaded that wife of complainant namely Smt. Anila Mahajan was also insured in the mediclaim policy. It is pleaded that complainant sought reimbursement of mediclaim of his wife namely Smt. Anila on 21.1.2014 and submitted mediclaim bills amounting to Rs. 6,58,566.04 (Six lacs fifty eight thousand five hundred sixty six rupees and four paise). It is pleaded that wife of complainant died on 15.10.2015. It is pleaded that opposite party did not settle the claim despite several requests and committed deficiency in service. Complainant sought relief of payment of entire mediclaim bills along with interest @ 18% per annum. In addition complainant sought relief of payment of Rs. 1,00,000 (One lac) for mental harassment. In addition complainant sought relief of payment of litigation costs to the tune of Rs. 25,000 (Twenty five thousand). Prayer for acceptance of consumer complaint sought.

3. Per contra version filed on behalf of opposite party pleaded therein that services of Third Party Administrator (TPA) licensed under IRDA sought. It is pleaded that mediclaim submitted by complainant does not fall within purview of Insurance policy and falls within the exclusion clause because wife of complainant was suffering from pre-existing disease i.e. Diabetes and Hypertension and complainant does not disclose pre-existing disease of his deceased wife to Insurance company. It is pleaded that Insurance company did not commit any deficiency in service. It is pleaded that mediclaim bills were repudiated strictly as per exclusion Clause No. 4.1 of Insurance policy. Prayer for dismissal of consumer complaint sought.

4. Complainant filed rejoinder and pleaded that opposite party has approved amount of Rs. 19,186 (Nineteen thousand one hundred eighty six) in favour of complainant against claim amount of Rs. 52,549 (Fifty two thousand five hundred forty nine). It is pleaded that as Insurance Company has approved the claim of Rs. 19,186 (Nineteen thousand one hundred eighty six) in part and Insurance Company could not be allowed to approbate and reprobate at the same time. Learned District Forum dismissed the consumer complaint. Feeling aggrieved against order passed by learned District Forum complainant filed present appeal before State Commission.

5. We have heard learned Advocates appearing on behalf of parties and we have also perused entire record carefully.

6. Following points arise for determination in present appeal.

1. Whether appeal filed by appellant is liable to be accepted as mentioned in memorandum of grounds of appeal and whether onus is upon Insurance Company to prove pre-existing disease of insured by way of affidavit of Medical Officer and whether non sending of final report of TPA appointed under Insurance Regulatory and Development Authority Regulation 2001 to insured by Insurance company amounts to deficiency in service on behalf of Insurance Company and whether exclusion clause can be used against insured when terms and conditions of exclusion clause were not explained to insured?

2. Final order.

Findings upon point No. 1 with reasons:

7. Complainant filed affidavit Ext.CW-1 in evidence. There is recital in affidavit that deponent purchased PNB Oriental Royal Mediclaim Policy No. 263201/48/2013/3333 on dated 13.3.2013 which was renewe