IMPORTANT POINT
There should be nexus with pre-existing disease & disease for which claim has been made.

ORDER

The present Revision Petition (RP) has been filed by the Petitioner against Respondent as detailed above, under section 58 1 (b) of Consumer Protection Act 2019, against the order dated 17.06.2022 of the State Consumer Disputes Redressal Commission Madhya Pradesh (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No.397 of 2015 in which order dated 17.06.2022 of District Consumer Disputes Redressal Commission Jabalpur (hereinafter referred to as District Commission) in Consumer Complaint (CC) No.64 of 2014 was challenged, inter alia praying for setting aside the order of the State Commission dated 17.06.2022 of the State Commission.

2. The Revision Petitioner (hereinafter also referred to as OP) was Appellant before the State Commission and OP(s) before the District Forum, the Respondent (hereinafter also referred to as Complainant) was the Respondent before the State Commission and Complainant before the District Forum.

3. Notice was issued to the Respondent on 18.08.2022. The Petitioner filed Written Arguments/Synopsis on 08.02.2024. Respondent also filed Written Arguments / Synopsis on 27.01.2022 and 03.01.2024.

4. Brief facts of the case as presented by the Complainant and as emerged from the RP, Order of the State Commission, Order of the District Commission and other case records are that Complainant purchased SBI Life Hospital Cash Policy on 26.01.2012 by paying a premium of Rs.4159/-. The maturity of the policy was due in the year 2015. As per the payment schedule given by the OP, the Complainant paid the instalments from time to time.

5. It is further the case of the Complainant that OPs issued information letter on 31.01.2014 to the Complainant that sum assured has been enhanced from 2,00,000/- to 2.10,000/- which was further enhanced to Rs.2,20,000/-. The Complainant started experiencing urine problem in March 2011. The Complainant consulted doctor who advised him treatment for optical internal urethrotomy. The Complainant again faced problem in May 2012 and was comfortable after taking antibiotic medicines. The said problem again occurred in May 2012. He was hospitalized for one day care in Mahakoshal Hospital, Jabalpur. The complainant incurred medical expenses, which he claimed with the OP. The OP, however, repudiated the claim on the ground that 24 hour hospitalization is must for claiming a medical expenses and day care is not covered.

6. The Complainant again started experiencing problem related to urine, for which he consulted Dr. N P Gupta, Urologist of Medanta Global Health Pvt. Ltd. Gurgaon. The doctor suggested operation for ‘Recurrent Stricture urethra Proximal Bulbar Area’. He was operated at the said hospital. It is the case of the Complainant that he incurred Rs.1,03,240/. Complainant submitted his claim to the OP but the same was again repudiated by the OP on the ground that it is a pre existing disease and his policy stand cancelled and no further premium will be accepted under the said policy. Being aggrieved, the Complainant filed CC before the District Forum and District Forum vide order dated 15.04.2015 directed as under:

a. Non applicant jointly or separately, within one month restore the mediclaimof the Complainant and pay the amount and also pay interest on the claimed amount at the rate of 8% p.a. from the date of cancellation of insurance claim from 03.02.2014.

b. Non-applicant jointly or separately will pay Rs.500/- to the complainant and will also pay Rs.1000/- towards litigation expenses within one month otherwise non applicant on non payment of awarded amount, will pay interest @ 10% p.a. till the realization.

7. Being aggrieved, the OPs preferred Appeal before the State Commission and State Commission and State Commission vide order dated 17.06.2022 upheld the order of the District Forum. Therefore, the Petitioner is before us now in the present RP.

8. Petitioner had challenged the said Order dated 17.06.2022 of the State Commission mainly on following