IN THE HIGH COURT OF GUJARAT AT AHMEDABAD R/SPECIAL CIVIL APPLICATION NO. 1664 of 2024 FOR APPROVAL AND SIGNATURE:

HONOURABLE MR. JUSTICE ANIRUDDHA P. MAYEE Sd/-

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Approved for Reporting Yes No No ================================================================

GUNVANTBHAI BHOGILAL SHAH Versus UNITED INDIA INSURANCE CO. LTD. & ORS.

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Appearance:

MR GUNVANT B SHAH(3859) for the Petitioner(s) No. 1 MR SAMIR B GOHIL(5718) for the Petitioner(s) No. 1 MR PALAK H THAKKAR(3455) for the Respondent(s) No. 1 NOTICE SERVED for the Respondent(s) No. 2 MR HARSHESH R KAKKAD(7813) for the Respondent(s) No. 3 ================================================================

CORAM:HONOURABLE MR. JUSTICE ANIRUDDHA P. MAYEE Date : 11/02/2026

ORAL JUDGMENT

1. By the present writ petition, the petitioner impugns the order dated 18.10.2023 passed by the National Consumer Disputes Redressal Commission, New Delhi [“National Commission” for short] in Revision Petition Nos.957 of 2020 and 61 of 2021 whereby the complaint preferred by the petitioner has been dismissed.

2. The brief facts in the present case are that, the petitioner along with his wife availed Group Medical Insurance Scheme from the respondent No.1 insurance company through the respondent No.3 trust in the year 2015. That the petitioner and his wife were covered under the insurance policy for the sum of Rs.5,00,000/-. That on 28.05.2017, the petitioner’s wife came to be admitted and operated for total knee replacement of her left knee. The petitioner incurred a bill of Rs.2,25,929.35/- towards the medical expenses. The petitioner thereafter lodged a claim for the said amount with the respondent No.1 insurance company through its TPA i.e. respondent No.2 herein. That by a communication dated 23.11.2017, the petitioner was informed that the respondent No.1 insurance company had rejected his claim on the ground that as per the policy conditions, there was a 3 years waiting period for degenerative diseases before being eligible for any reimbursement.

2.1 Aggrieved, the petitioner filed a complaint before the District Consumer Disputes Redressal Forum, Ahmedabad. The complaint came to be dismissed vide order dated 30.07.2018. That thereafter, the petitioner filed Appeal No.714 of 2018 before the State Consumer Disputes Redressal Commission, Ahmedabad [“State Commission” for short]. By order dated 29.11.2019, the appeal came to be partly allowed and the respondent No.1 insurance company was directed to pay a sum of Rs.1,50,000/- as full and final settlement towards the medical claim of the petitioner.

2.2 Aggrieved by the said order, the petitioner as well as the respondent No.1 insurance company filed Revision Petition No.61 of 2021 and Revision Petition No. 957 of 2020 respectively before the National Commission. By the common impugned order dated 18.10.2023, the National Commission has rejected the complaint of the petitioner and set aside the order dated 29.11.2019 passed by the State Commission and allowed the revision petition of the respondent No.1. 3. Mr. G.B.Shah, learned advocate for the petitioner submits that the National Commission has wrongly relied on the exclusion Clause 4.4 of the policy conditions placed on record by the respondent No.1 insurance company wherein lock-in period is of

48 months before any claim for degenerative disease can be taken. He submits that the said condition is a general condition in the medical claim policy of the respondent No.1 insurance company. He submits that there is a total non-application of mind. He submits that the respondent No.1 insurance company had created a special medi-claim policy for the beneficiaries of the respondent No.3 trust. The petitioner being a beneficiary, was entitled for the medi-claim upto the sum of Rs.5,00,000/-. He submits that no terms and conditions of the policy were ever supplied to the petitioner. He