ORDER

The present Revision Petition (RP) has been filed by the Petitioner against Respondent as detailed above, under section 21(b) of Consumer Protection Act, 1986, against the order dated 22.11.2018 of the State Consumer Disputes Redressal Commission, Punjab (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 253/2018 in which order dated 15.06.2017 of District Consumer Disputes Redressal Forum, Ludhiana (hereinafter referred to as District Forum) in Consumer Complaint (CC) No. 334 of 19.05.2015 was challenged, inter alia praying for setting aside the order dated 15.06.2017 passed by the District Forum and order dated 22.11.2018 passed by the State Commission.

2. While the Revision Petitioner(s) (hereinafter also referred to as Complainant) was Appellant before the State Commission and Complainant before the District Forum and the Respondent (hereinafter also referred to as OP/Insurance Company) was Respondent before the State Commission and Opposite Party before the District Forum. Notice was issued to the Respondent on 27.03.2019. Parties filed Written Arguments on 10.11.2022 (Petitioner) and 13.02.2023 (Respondent) respectively.

3. 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: -

The complainant and his wife Smt. Anju are holders of medi-claim policy effective from 29.08.2014 to 28.08.2015 and have been insured for Rs.5,00,000/- each under the said policy issued by the Respondent/Insurance Company. Earlier, the complainant had got himself medically insured from “Reliance General Insurance” from 10.06.2008 to 09.06.2014. On 27.01.2015, the complainant suffered from chest pain and was admitted in emergency ward for treatment at Hero D.M.C. Heart Institute, Ludhiana. The complainant remained admitted in Hero D.M.C. Heart Institute, Ludhiana from 27.01.2015 to 01.02.2015 and was treated for Coronary Angiography Double Vessel Disease PTCA with Stenting TO OM1. The complainant spent a sum of Rs.1,76,146/- (Rs.1,65,955/- paid to the DMC Heart Institute for the said treatment + spent a sum of Rs.10,191/- on medicines purchased from Medical Hall on 01.02.2015, 01.02.2015 and on 07.02.2015 + a sum of Rs.300/- on account of consultation charges with Dr. G.S. Wander). The complainant submitted his claim to the Respondent/Insurance Company alongwith all the documents in original including Hospital Bill and pharmacy bills for settlement of claim. Vide letter dated 23.02.2015, the Insurance Company repudiated the claim on the ground that that “From documents it is noted that patient is known case of Hypertension since 10 years (PA), since the ailments are found to be present prior to the inception of policy and is going beyond the coverage of the present policy, hence, claim is repudiated under policy clause 4.1, 4.2. Hence, the claim is being denied.” Hence, the complainant filed complaint before the District Forum.

4. Vide Order dated 15.06.2017, the District Forum dismissed the complaint No.334 of 19.05.2015.

5. Aggrieved by the said Order dated 15.06.2017 passed by the District Forum, Complainant appealed before the State Commission and the State Commission vide order dated 22.11.2018, dismissed the Appeal No. 253/2018.

6. Petitioner/Complainant has challenged the said Order dated 22.11.2018 of the State Commission mainly on the following grounds:

i) The order dated 15.06.2017 passed by the District Forum and order dated 22.11.2018 passed by the state Commission dismissing the complaint on the ground that medical condition of the complainant qua sufferance from hypertension before filling up the proposal form, was not disclosed and hypertension is a precursor to the heart disease and could be attributed as one of the significant cause for heart disease and M/s Medi Assist India TPA has not repudiated the claim in haste, but referred the case to Singla’s Clinic for gettin