Date of filing :07.12.2018 Date of order :13.01.2026 MAHARASHTRA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,MUMBAI, BENCH AT AURANGABAD.

FIRST APPEAL NO. : 571 OF 2018 IN COMPLAINT CASE NO.: 204 OF 2015 DISTRICT CONSUMER FORUM : AHMEDNAGAR.

Oriental Insurance Co.Ltd., Appellant Through its Divisional Manager, (Adv.J.K.Narayane)

D.O.No.II, Adalat Road, Aurangabad, District Aurangabad.

VERSUS

1. Sanjog Vinodlal Mutha, Respondent No.1 and 2 R/o Barde Galli, Ahmednagar. (Adv.Pratik P.Kothari)

2. Vinodlal Zumberlal Mutha, R/o Barde Galli, Ahmednagar.

3. M.D.India Health Care Services Pvt.Ltd. Respondent No.3 R/o M.D.India, 147/8, Near Kothruad (Not proceeded with)

Petrol Pump, Karve Statue Circle, Kothrud, Pune-411 038, Present Address, Survey No.46/1, E-Space, A2 Building, 3rd Floor, Pune Nagar Road, Wadgaon Sheri, Pune 411 014.

CORAM : Milind S.Sonawane, Hon’ble Presiding Member.

Nagesh C.Kumbre, Hon’ble Member

J U D G M E N T

(Delivered on 13.01.2026)

Per Milind S.Sonawane, Hon’ble Presiding Member.

This is an appeal challenging correctness and legality of the judgment and order passed by the learned District Consumer Disputes Redressal Commission, Ahmadnagar (the ‘District Commission’ for shrt) in C.C.No. 204/2015, whereby the District Commission allowed the complaint filed by the respondents directing the appellant to pay to them sum of Rs.4,57,755/- towards the insurance claim along with Rs.20,000/- for the mental and physical harassment and Rs.5,000/- as the costs of the proceedings.

2. The brief facts of the appeal are that, the respondents in 2005 took the mediclaim policy from the appellant. It was renewed over the number of years till 2013. On 31.07.2013, the son of respondent no.2 i.e. respondent no.1 upgraded the policy by taking ‘family floater basic cover’ of Rs. 7 Lakh and personal accident cover of Rs. 35 Lakh under the ‘gold plan’. In this manner the entire family of the respondents was covered under the policy. When the policy cover was available from 31.07.2014 to 30.07.2015, respondent no.2 was admitted on 19.01.2015, firstly in Noble Hospital, Ahmadnagar. He was diagnosed to have heart attack. He was admitted in that hospital till 25.01.2015. He incurred expenses of Rs. 62,588/-. Thereafter, he was admitted from 25.01.2015 to 05.02.2015 in Rubby Hall Clinic, Pune for the bypass surgery. There he incurred expenses of sum of Rs.4,74,264/-. Thereafter also for the same reason, he was admitted again in Nobel Hospital, Ahmadnagar from 07.02.2015 to 10.02.2015. He incurred sum of Rs. 20,633/- on the post operative treatment. As such, in total, respondent no.2 has incurred Rs. 5,57,755/- on medical treatment.

3. The respondents lodged the insurance claim for the above treatment with the appellant. The appellants however just paid Rs.1 Lakh for the insurance claim and on 22.04.2015 issued a letter stating that, the balance claim is repudiated, as the insured person has exhausted his applicable sum insured for the year. Against that repudiation the respondents filed the above mentioned Consumer Complaint before the District Commission, in which the impugned judgment is passed.

4. The appellant appeared before the District Commission and resisted the case filed by the respondents. It was contended that, since the sum insured for initially issued policy to respondent was Rs.1 Lakh and that subsequently in 2013 that policy was upgraded and enhanced to the insured sum of Rs. 7 Lakh and that, the disease for which respondent no.2 was treated and operated in 2015, is for the pre-existing ailment, which was not covered for four continuous years as per the policy term clause No.4.1 and 4.3. The repudiation is valid. There is no deficiency in service caused to the respondents. They prayed that, the complaint filed by the respondents may kindly be dismissed with costs.

5. The District Commission on evaluating the evidence before it and on hearing the learned Counsels of both sides drawn the conclusion that, the appellant has not adduced any