IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution: 19.10.2016 Date of Hearing: 14.11.2025 Date of Decision: 03.12.2025 FIRST APPEAL NO.-489/2016 IN THE MATTER OF M/S ORIENTAL INSURANCE CO. LTD.

REGIONAL OFFICE 2, IST FLOOR, CORE-I, SCOPE MINAR, LAXMI NAGAR DISTT. CENTRE DELHI THROUGH ITS REGIONAL MANAGER …APPELLANT (Through: Mr. Rajiv Jaiswal, Advocate Mob.9871901997 &

Email: rajivjaiswal1954@gmail.com)

VERSUS MR. JOGINDER PAL ARORA, R/O D-294, VIVEK VIHAR-I, DELHI-110095 ….RESPONDENT CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

HON’BLE MS. PINKI, MEMBER (JUDICIAL)

Present: Ms. Sheetal Ojha, counsel for the appellant.

None for the respondent.

PER : HON’BLE PINKI, MEMBER (JUDICIAL)

JUDGMENT

1. The present Appeal (First Appeal) has been filed by the Appellant against Respondent as detailed above, against the order dated 19.08.2016 passed by the District Consumer Disputes Redressal Commission, (District North) (hereinafter referred to as District Commission) in Complaint (CC) No. 427/2009, inter-alia praying for setting aside the order passed by the District Commission.

2. While the Appellant was Opposite Party before the District Commission and the Respondent was Complainant before the District Commission.

3. The facts of the case as per the District Commission-X, record are as under:

“1. The complainant has filed the present complaint against the O.P under section 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant had taken mediclaim policy since 1998 and lastly renewed vide policy bearing No.271301/2006/1609 for the period from 11.09.2005 to 10.09.2006 from the O.P. It is alleged that the complainant fell ill and was admitted in Batra Hospital for his treatment. It is further alleged that the complainant submitted a bill of medicines and regarding the payment of Rs.90,000/- to the O.P but the O.P repudiated the claim of the complainant on flimsy grounds. It is alleged that the claim of the complainant was rejected by the O.Ps on the false frivolous opinion of Vipul Medcrop Pvt. Ltd. On these facts complainant prays that O.P be directed to pay a sum of Rs.90,000/- with interest and also to pay cost and compensation as claimed.”

4. The District Commission after taking into consideration the material available on record passed the judgment dated

19.08.2016, whereby it held as follows:

“5. The main controversy in this case pertains to rejection of claim filed by the complainant with O.P. The reason for rejection is that the complainant was known case of Diabetes Mellitus for 5 years, known case of impared, renal function, peripheral, oedema on & off and difficulty in urination. The O.P examined the claim of complainant through its TPA and came to the conclusion that though the insured had mediclaim policy since 22.08.1998 but there was a gap of 21 days in the policy for the period 11.09.2002 to 10.09.2003 and a such there was no continuity of mediclaim policy also it was a case of pre- existing disease for the last 5 years. Therefore, the O.P rejected the claim while relying on the exclusion clause 4.1. The exclusion clause 4.1 as mentioned above. The policy examined by the forum does not have the terms and conditions of O.P. The terms and conditions is a separate full-fledged document which was produced during the course of proceeding and the same was never supplied to the injured so that he could make up his mind as to whether he would go for this mediclaim policy or not. The injured appears to have been taken by surprise by the insurance company by subsequently showing the terms and conditions unsuitable to the interest of the injured. This practice of insurance company while executing mediclaim policy is highly deprecated because it has a tinge of mal-practice and deceit. The Hon’ble State Commission in case tilted Aviva Life Insurance Claim Department Vs. Sharanjeet Kaur IV (2014) CPJ 124 (PUNJ)

held as under:

“In this case, death-claim was repudiated o