IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution: 06.10.2023 Date of Hearing: 04.02.2026 Date of Decision: 24.03.2026 First Appeal No. -528/2023 IN THE MATTER OF THE ORIENTAL INSURANCE CO. LTD., LEGAL HUB, A-25/27, ORIENTAL HOUSE, ASAF ALI ROAD, NEW DELHI-110002.

(Through: Mr. Bhupesh Kumar Chandna, Advocate)

…Appellant VERSUS

1. MR. ABHISHEK CHAUHAN, S/O MR. PRADEEP CHAUHAN, R/O 1140, GALI NO. 12, B-BLOCK, BURARI, NEW DELHI-110084.

2. MR. PRADEEP CHAUHAN, R/O 1140, GALI NO. 12, B-BLOCK, BURARI, NEW DELHI-110084.

(Through: Mr. K. S. Rana, Advocate)

…. Respondents CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

HON’BLE MS. BIMMLA KUMARI, MEMBER (FEMALE)

Present: Mr. Bhupesh Kumar Chandna, counsel for the Appellant appeared through VC.

Mr. Pradeep Chauhan, father of the Appellant.

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

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

“1. The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986. The brief details of facts, as alleged by the Complainants in the Complaint in hand, are that the Complainants were the policy holder of PNB-Oriental Royal Mediclaim Insurance Policy No.272900/48/2016/28409 having validity from 30.03.2016 to 29.03.2017. At around 07:00 PM on 16.07.2016, Complainant No.1 was hit by an unknown vehicle and being injured, was admitted in Babu Jagjiwan Ram Memorial Hospital, Delhi-110033 vide MLC No.118511. Thereafter, for better treatment, Complainant No.1 was admitted in the Fortis Hospital, A-Block, Shalimar Bagh, Delhi-110088 on 20.07.2016 where his Surgery and other treatment was done. The treatment record has been filed with complaint as Ex.CW- 1/2. The Fortis Hospital, on discharge of complainant no.1, raised a bill of Rs.1,50,988/- which was paid by Complainant No.2. The Complainant filed claim with OP insurance company seeking reimbursement of the above said amount vide I.D. No.13010435 on 16.07.2016 but the Opposite Party repudiated the claim vide letter dated 12th December, 2016 explaining the reasons of repudiation with the following wording:-

"As per FIR, patient having smell of alcohol consumption, hence denied under clause 4.7"

2. It has been alleged by the complainants that the act of OP for rejection of the reimbursement claim, amounts to deficiency in service for which the OP is liable. Therefore, the complainant has filed this Complainant praying for directions to OP to reimburse claim amount of Rs.1,50,998/- and payRs.50,000/- as compensation amount for suffering caused by the OP due to deficiency in service and Rs.11,000/- as. cost of legal notice. Accordingly, notice was issued to the OP and in response, the OP has filed its reply stating that the complaint is not maintainable and liable to be dismissed as there is not deficiency of services on the part of the OP. The aforesaid complaint so made by the Complainant under the explained circumstances is not tenable as per the law. It is further contended by the OP that the Complainant No.1 was treated by the Hospital concerned for the injuries sustained in an accident due to own act & conduct being alcoholic las . per FIR & MLC], and as per policy wordings, the claim of the Complainant was found not payable under the exclusion clause 47". Therefore, the claim filed by the complainants was rightly repudiated vide repudiation letter dated 12.12.2016". The provisions mentioned in Exclusion Clause No.4.7, of the policy are reproduced below:-

"All psychiatric and psychosomatic disorders and diseases/ accident due to and use, misuse or abuse of drugs/alcohol or alcohol or use of intoxicating substances or such abuse or addiction etc".

2. The District Commission after taking into consideration the material available on record passed the order dated 23.08.2023 whereby it held as under:

“4. As such, the complaint has been examined in view of the facts of the case and averments/documents/Evidence put forth by