STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH First Appeal No.225 of 2023 Date of institution : 28.03.2023 Date of Reserve : 22.05.2025 Date of Decision : 23.06.2025 The Oriental Insurance Company Ltd., through its Branch Manager Branch Office II, SCO 50, Jeevan Raksha, PUDA Complex, Opposite Tehsil, Jalandhar-144001 (Punjab).

Now through Regional Manager, Oriental Insurance Company Ltd., Regional Office, Surendra Building, SCO No.109-111, Sector 17-D, Chandigarh …….Appellant/Opposite Party Versus Sh.Ravinder Kumar S/o Sh.Dharam Pal, resident of H.No.333/7, Central Town, Jalandhar also residing at 174/4, Central Town, Jalandhar.

…...Respondent/Complainant First Appeal under Section 41 of the Consumer Protection Act, 2019 against the Order dated 08.12.2022 passed by the District Consumer Disputes Redressal Commission Jalandhar in CC No.129 of 2019.

Quorum:-

Hon’ble Mrs. Justice Daya Chaudhary, President Ms. Simarjot Kaur, Member Mr. Vishav Kant Garg, Member

1) Whether Reporters of the Newspapers may be allowed to see the Judgment? Yes/No

2) To be referred to the Reporters or not? Yes/No

3) Whether judgment should be reported in the Digest? Yes/No Present :-

F or the appellant : Sh.Ram Avtar, Advocate For the respondent : Sh.Vinay Puri, Advocate SIMARJOT KAUR, MEMBER This Appeal has been filed by the Appellant/Opposite Party under Section 41 of the Consumer Protection Act, 2019 (in short ‘The Act’) being aggrieved by the impugned Order dated 08.12.2022 passed by the District Consumer Disputes Redressal Commission Jalandhar (in short ‘the District Commission’)

whereby the partly allowed the Complaint of the Complainant.

2. It would be apposite to mention that hereinafter the parties will be referred, as had been arrayed before the District Commission.

3. Briefly, the facts of the case as made out by the Complainant before the District Commission are that the Complainant had obtained a Medical Insurance Policy No.233108/48/2018/2299. The sum assured for the policy was Rs.5 lac. The premiums had been regularly paid by the insured. The policy was valid w.e.f. 07.10.2017 to 06.10.2018. The policy was got renewed from 07.10.2018 to 06.10.2019. The said policy was never got cancelled or terminated by the Complainant. The Complainant had suffered some medical problem on 02.06.2018 and he got himself medically checked at DMC Hospital, Ludhiana as an outdoor patient till 08.06.2018. At that time, BP problem was diagnosed/detected. Thereafter, he suddenly suffered from medical problem of breathlessness for the first time. He was admitted in Dayanand Medical College & Hospital, Ludhiana on 10.07.2018 and discharged on 21.07.2018. During the treatment of the Complainant, AICD (MEDTRONICE, SINGLE CHAMBER) was done on 16.07.2017. The Complainant had spent an amount of Rs.4.29,167.74 towards his treatment. It was covered under Medical Insurance Policy for Rs.5 lac issued by OP. The Complainant had filed his Insurance Claim for reimbursement of the medical expenses but the OP had denied the same vide letter dated 17.12.2018. It was rejected as per clause 4.1 and 4.2 of the terms and conditions of the Insurance Policy. His claim had been rejected on the ground that he was a known case of HTN Since 8 years. The Policy had commenced from 2016 onwards. Therefore, Hypertension (HTN) diagnosed before the inception of the said policy. It was a case of pre-existing disease (PED). The claim for pre-existing disease was payable only after three years of the policy whereas the policy of the Complainant was in its second year thus the claim was not payable as per clause 4.1.

4. It was mentioned in the Complaint that the opinion of the Doctor of DMC, Ludhiana, who attended the Complainant was given as below :

HOSPITAL COURSE: Patient was admitted outside, due to ECG and echocardiography changes shifted to HDHl for further management. BNP was raised. Echocardiography was done which showed detailed cardiomyopathy, severe LVB systolic dysfunction, LVEF-1