M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PLOT NO. 76, ARERA HILLS, BHOPAL (M.P.)

FA No.459/ 2017.

Oriental Insurance Company Ltd., Bhopal through Divisional Manager, Divisional Office No.1, Oriental Insurance Company, Bersia Road, Bhopal (M.P.). …. APPELLANT.

Versus

1. Smt. Moti Rani Jain w/o Late Shri Indramohan

2. Chhavindra Kumar Jain s/o Late Shri Indramohan

3. Bhupesh Jain, s/o Late Shri Indramohan All resident of : Ward No.5, Narsingh Ward, Harda (M.P.).

4. M/s Medi Assist India, No.4/1, R.B.C. Tower D.

4^th Floor, Bangalore 460 029. 5. Punjab National Bank, Through Branch Manager, Branch Harda (M.P.). ….RESPONDENTS.

BEFORE:

HON’BLE SHRI JUSTICE SHANTANU S. KEMKAR, PRESIDENT HON’BLE DR. (SMT) MONIKA MALIK, MEMBER COUNSEL APPEARING FOR THE PARTIES :

Shri Ravindra Tiwari, learned counsel for the appellant.

Shri Deepesh Joshi, learned counsel for the respondent No.1 to 3.

None for the respondent No.4 and 5.

O R D E R

(Passed on 24 / 05 / 2023)

The following order of the Commission was delivered by Shantanu S.

Kemkar, J :

Challenging the repudiation letter dated 20.7.2016 issued by the appellant – Insurance Company by which insured’s claim seeking compensation payable to him for the expenses incurred by him during his hospitalization under the ‘PNB Oriental Royal Mediclaim Insurance Policy’ obtained by him has been rejected, the insured – Indramohan Bajaj had filed a Complaint Case No.113/2016 before the District Consumer Disputes Redressal Commission, Harda (for short the ‘District Commission’). The District Commission vide impugned order dated 9.2.2017 allowed the complaint and directed the appellant – Insurance Company to pay compensation of Rs.3,43,740/- for the expenses incurred by him and Rs.3,000/- for mental agony with a further condition that in case the said amount is not paid within 30 days it shall carry interest @12% p.a. In addition Rs.1000/- have been awarded towards cost. Feeling aggrieved, the appellant –

Insurance Company has filed this appeal.

2. Briefly stated the insured – Indramohan Bajaj had filed a complaint case stating therein that he had taken ‘PNB Oriental Royal Mediclaim Insurance Policy’ from the fifth respondent – Punjab National Bank, who was working as agent of the appellant / Insurance Company. The said insurance policy was valid from 25.9.2014 to 24.9.2015.

He stated that on 12.11.2014 he had gone to Nagpur from Harda for attending a wedding. On 12.11.2014 during the wedding ceremony itself he felt pain in his chest and as such his son took him to Dr. Uday Mahokar, who after initial examination advised to admit him in Avanti Hospital, Nagpur. After all necessary investigation at Avanti Hospital as was advised by the treating doctor his angioplasty was done.

3. The complainant further stated that in his treatment and angioplasty at Avanti Hospital he incurred expenses of Rs.3,43,740/- for angioplasty and Rs.22,740/- towards the medicines. Since he was insured with the appellant he claimed the said amount with compensation of Rs.20,000/-. However his claim was denied by the appellant / insurer vide repudiation letter dated 20.7.2016, Ex.P/25 by stating following reasons :-

“Patient was admitted with the complaints of Diagnosis with IHD with the risk factor of obesity. The patient with diagnosed DVD with 90% stenosis+60% stenosis. Plaque that accumulates on the inner walls of your arte made from various substance that circulate in your blood. As plaque deposits grow, a condition called atherosclerosis results. This condition causes the arteries to narrow and harden. Plaque often starts to develop during the childhood or teenage years. Then clogged arteries develop in middle age or later. Considering the accumulation is a time taking procedure which cannot just happen in 1 day or few months, which the patient suffering prior to the inception of the Policy. Date of inception of the Policy is from 25 Sept. 2014. Hence the claim is falling under Exclusion 4.1 and is being denied. We also reserve the right to r