Exclusion clauses in insurance policies are enforceable unless deemed unfair or against public policy, and consumers are presumed to accept terms if not disputed during the free look period.

JUDGMENT

Vinod S. Bhardwaj, J. (Oral)

Challenge in the present writ petition is to the award dated 26.10.2021 passed by the Permanent Lok Adalat (Public Utility Services), Ludhiana in Case Bearing No.29/2019 titled as 'Anuj Kumar Sehgal v. Bajaj Allianz General Insurance Company Limited'.

2. The undisputed facts that emerge from the pleadings are to the effect that respondent No.2-applicant/Anuj Kumar Sehgal had purchased a family health insurance Policy bearing No.OG191000602100035362 bearing customer ID No.123377999 valid w.e.f. 21.07.2018 to 20.07.2019 under which medical claim upto Rs. 5 lakh for respondent No.2-applicant/Anuj Kumar Sehgal and his wife Ms. Shabnam was covered. As per the case of respondent No.2-applicant/Anuj Kumar Sehgal, on 08.08.2018 when he was travelling to Gurugram along with his wife and relative Arun Sehgal, he suddenly felt acute abdominal pain and was immediately shifted to Shri. Ji Clinic Gurugram. The medical investigation was undertaken to rule out the possibility of Cardiac arrest. After a brief hospitalization and tests ruling out Cardiac issues, he was discharged. On his way back to Ludhiana, he felt the acute pain yet again and was taken to Adesh Medical College and Hospital, Shahabad, Ambala Cantt., where he remained admitted for about one and a half hours and was then shifted to Deep Hospital, Ludhiana. The medical investigation diagnosed the abdominal pain due to appendicitis. He was operated in an emergency on 09.08.2018 and the total expenses incurred by him for said treatment were Rs. 1,51,554/-. The claim submitted by him for reimbursement of the medical expenses incurred was repudiated by the petitioner-Insurance Company by referring to the exclusion clause.

3. As the aforesaid factual aspects are not in dispute, they need not be dealt with any further. The only point which arises for consideration before this Court is as to whether the petitioner-Insurance Company had rightly repudiated the claim submitted by the petitioner or the reasons cited by it were unsustainable.

4. Learned counsel for the petitioner-Company has drawn the attention of this Court to the terms and conditions of the Policy documents and he makes a specific reliance on the exclusion No.4 of Clause 49 of the Policy document which reads thus:

"4. Any disease contracted and/or medical expenses incurred in respect of any disease/illness by the insured during the first 30 days from the commencement of the policy, except for accidental injuries".

5. Referring to the above, it is submitted that the Policy in question was taken on 21.07.2018 and that no medical expenses incurred on any disease/illness was to be indemnified by the Insurance Company within a period of 30 days from the commencement of the Policy. Since the commencement date of the Policy was from 21.07.2018 and the expenses for medical treatment were incurred by the petitioner on 09.08.2018, hence, the said expenses were with respect to a treatment within a period of 30 days of the issuance of the Policy. He contends that the exclusion being specific and fully known to respondent No.2-applicant, the claim for medical reimbursement was wrongly awarded by the Permanent Lok Adalat (Public Utility Services) while allowing the application. The essential terms and conditions of the Policy have not been taken into consideration by the Permanent Lok Adalat (Public Utility Services), rendering the award liable to be set aside.

6. Learned counsel appearing on behalf of respondent No.2- applicant however submits that even though there is no dispute with respect to the aforesaid clause of the Policy, however, the pain in question was detected suddenly and that such an exclusion cannot be applied under such circumstances as it would be unfair, unjust and inequitable. He submits that it was a case of unjustifiable denial of the benefits of insurance policy which was obtained for such exigent requirements.

7. I have heard the learned counsel appearing on behalf of the resp