IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution: 31.12.2015 Date of Hearing: 09.01.2023 Date of Decision: 09.05.2023 FIRST APPEAL NO.- 638/2015 IN THE MATTER OF M/s ORIENTAL INSURANCE CO. LTD., A-25/27, Asaf Ali Road, New Delhi – 110002.

(Through: Mr. Bhupesh Kumar Chandna, Advocate)

…Appellant VERSUS MR. SURINDER MAHAJAN, R/o G-208, Naraina Vihar, New Delhi – 110028.

(Through: Mr. Yogesh Kumar Gupta, Advocate)

… Respondent CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

HON’BLE PINKI, MEMBER (JUDICIAL)

HON’BLE J.P. AGRAWAL, MEMBER (GENERAL)

Present: None for the Appellant.

Mr. Hans Raj, proxy counsel for Mr. Y. K. Gupta and Mr. Harpreet Singh, counsel for the Respondent.

PER: HON’BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT JUDGMENT

1. The facts of the case as per the District Commission record are:

“In the year 2003, the complainant had subscribed to mediclaim insurance policy from M/s National Insurance Company Ltd. He had renewed the policy from time to time till 12.6.2012. W.EF. 12/6/2012 he had shifted to the mediclaim policy floated by OPI which was effective for the period 12-6-2011 to 12-6-2012. On 12- 02-2012, the complainant was admitted to Sir Ganga Ram owing to severe pain in the right lower limb. He was discharged from the hospital on 25.2.2012 and had incurred a sum of Rs 307896/ as expenses on the treatment. He had filed a claim with the OP1 for reimbursement which was repudiated vide letter dated 1.5.2012. It is alleged by the complainant that the repudiation of the claim was illegal and unjustified.”

2. The District Commission after taking into consideration the material available on record passed the order dated 02.02.2015, whereby it held as under:

“We have heard arguments advanced at the bar and have perused the record. The sole question for our determination is as to whether OP1 was justified in repudiating the claim lodged by the complainant. OP has claimd tha the claim was not payable as per exclusion clause 4.3 of the policy of insurance purchased by the complainant. The relevant portion of clause 4.3 of the insurance policy is reproduced as under:-

4.3 The expenses on treatment of following ailments/ diseases/ surgeries for the specified periods are not payable it contracted and/or manifested during the currency of the policy:

If these diseases are pre-existing at the time of proposal the exclusion no. 4.1 for pre-existing condition shall be applicable in such cases:

XXXXX XXXXX XXXX XXXXX XXXXX XXXX XXXXX XXXXX XXXX XXXXX XXXXX XXXX (xvi) Gout and Rhenumatism 2 Years (xvii) Hypertension 2 Years XXXXX XXXXX XXXX XXXXX XXXXX XXXX The learned counsel for the OP has forcefully contended that the complainant had purchased the policy from it for the first time on 12.6.2011 and, therefore, it has to be treated as a fresh h policy.

He has contended that the OP was, therefore, justified in repudiating the claim under clause 4.3 ibid The learned counsel for the complainant on the other hand has contended that the OP1 has failed to give the benefit of Health Insurance Portability. As per IRDA guidelines.

We have considered the contentions on both sides. Insurance Regulatory and Development Authority has issued guidelines on

9-9-2011 under the head portability it reads:-

1.1 Portability: Portability means the right accorded to an individual health insurance policy holder (including family cover) to transfer the credit gained by the insured for pre- existing conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another Insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break.

1.2 Break in policy: A break in policy occurs when the premium due on a given policy is not paid on or before the premium renewal date or within 30 days thereof.

A bare perusal of the aforesaid guidelines issued by IRDA makes it amply clear that the policy purchased by the complainant from OP1 in the year 2011