M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PLOT NO.76, ARERA HILLS, BHOPAL FIRST APPEAL NO.543 OF 2019 (Arising out of order dated 24.02.2016 passed in Case.No.107/2016 by District Commission, Jabalpur no.1)

UNITED INDIA INSURANCE COMPANY LIMITED, DIVISIONAL OFFICE – RAJKIRAN BHAWAN, 1454, RIGHT TOWN, JABALPUR. … APPELLANT.

Versus

1. DR. RAHUL AGRAWAL

2. SMT.SHASHI AGRAWAL

3. DR.EKTA AGRAWAL ALL R/O HOUSE NO.739, MADHATAL KARAMCHAND CHOWK, JABALPUR. .… RESPONDENTS.

BEFORE :

HON’BLE JUSTICE SMT.SUNITA YADAV, PRESIDENT HON’BLE DR. (MRS) MONIKA MALIK, MEMBER COUNSEL FOR PARTIES :

Shri Anurag Khaskalam, learned counsel for the appellant.

Shri Vivek Anand Nema, learned counsel for the respondents.

O R D E R (Passed on .04.2025)

The following order of the Commission was delivered by Dr.(Mrs) Monika Malik, Member :

This is an appeal by the opposite party / appellant –

United India Insurance Company Limited (hereinafter referred to as ‘Insurance Company’) directed against the order dated 24.02.2016 passed by the District Consumer Disputes Redressal Commission, Jabalpur no.1 (for short ‘District Commission’) in complaint case no.107/2016, whereby the District Commission has allowed the complaint filed by the complainants /

respondents.

2. Facts of the case in brief are that the complainants / respondents had obtained a group mediclaim policy no.19090048134100000803 from the Insurance Company for a period w.e.f. 16.10.2013 to 15.10.2014. The policy was renewed for a further period of one year. The complainant’s father (hereinafter referred to as ‘deceased’) developed pain in chest and therefore was admitted in Metro Infinity Hospital, Jabalpur for treatment on 07.07.2014. The deceased had no ailment regarding blood pressure previously. On 12.05.2015 the deceased died, regarding which the claim form alongwith treatment papers were submitted with the Insurance Company. It is alleged that the Insurance Company, despite fulfillment of requisite formalities denied the payment of claim amount on the basis of condition no.4.1 of the policy terms and conditions. Therefore, alleging deficiency in service against the Insurance Company the complainants approached the District Commission, seeking relief.

3. The Insurance Company resisted the complaint on the ground that the claim regarding pre-existing condition is payable after two full years and therefore, the claim is not payable as per condition no.4.1 of the policy terms and conditions.

4. The District Commission allowed the complainant and directed the Insurance Company to re-decide the payable claim amount and pay the same to the complainants within two months of receipt of copy of the order with interest @ 8% p.a. from the date of repudiation of claim i.e. 27.07.2015, till payment.

Compensation and costs of Rs.5,000/- is also awarded.

5. Heard. Perused the record.

6. Learned counsel for the Insurance Company argued that the claim is not payable on account of pre-existing ailment, since the claim regarding the same is payable after two full years. The complainants obtained the policy for the first time in the year 2013 and therefore the total period of 48 months has not elapsed for making payment regarding pre-existing condition. Therefore, the impugned order deserves to be set aside.

7. Learned counsel for the complainants / respondents argued that the deceased was admitted in the hospital because of chest pain on 07.07.2014. He had no history of hypertension or any other heart ailment prior to the said date. The deceased died of heart attack. Therefore, since the deceased did not have any heart related disease prior to obtaining the policy cover, the same cannot be termed to be a pre-existing condition. The Insurance Company has thus been deficient in service and the appeal therefore, deserves to be dismissed.

8. Annexure P-8 is the repudiation letter dated 18.12.2014 through which the Insurance Company has denied payment of the claim amount. In the said repudiation letter the Insurance Company has men