State Consumer Disputes Redressal Commission
The Oriental Insurance Co. Ltd. vs Shiv Kumar on 10 November, 2025
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH.
First Appeal No.632 of 2024
Date of institution : 25.10.2024
Reserved on : 28.10.2025
Date of Decision : 10.11.2025
1. The Oriental Insurance Co. Ltd., Branch K.C.Road, Barnala
through its Regional Office at SCO 109-111, Sector 17-D,
Chandigarh through its Deputy Manager.
2. The Oriental Insurance Company Ltd., Registered and Head
Office: A-25/27, Asaf Ali Road, New Delhi-110022 through its
Branch Manager.
....Appellants/Opposite Parties No.1&2
Versus
1. Shiv Kumar aged about 46 years son of Bhagwan Chand, resident
of # B-XI/617, Street No.7, K.C.Road, Barnala, Tehsil & District
Barnala, Punjab.
...........Respondent No.1/Complainant
2. Punjab National Bank, main Branch, Barnala through its Branch
Manager.
3. Medi Assist Insurance TPA Pvt. Ltd., Cashless Processing Centre
No.252/2 Kodichikkanahalli Main Road, opposite Kailash Building,
Bommanahalli, Banglore-56008 through its Managing
Director/Authorized Representative.
........Proforma Respondents/Opposite Parties No.2&3
First Appeal under Section 41 of the
Consumer Protection Act, 2019
against the order dated 05.08.2024
passed by the District Consumer
Disputes Redressal Commission,
Barnala in CC No.151 of 2022.
Quorum:-
Hon'ble Mrs. Justice Daya Chaudhary, President
Ms. Simarjot Kaur, Member
Mr. Vishav Kant Garg, Member FA No.632 of 2024 2
1) Whether Reporters of the Newspapers may be allowed to see the Judgment? Yes/No
2) To be referred to the Reporters or not? Yes/No
3) Whether judgment should be reported in the Digest?
Yes/No Present:-
For the appellants : Sh.Amit Jaiswal, Advocate For respondent No.1 : Sh.Vivek Salathia, Adv. for Sh.Vivek Singla, Advocate SIMARJOT KAUR, MEMBER :
The Appellants/Opposite Parties No.1&2 have filed the present Appeal to challenge the impugned order dated 05.08.2024 passed by the District Consumer Disputes Redressal Commission, Barnala (in short, "the District Commission"), whereby the Complaint filed by the Complainant had been partly allowed.
2. It would be apposite to mention here that hereinafter the parties will be referred, as were arrayed before the District Commission.
3. Briefly, the facts of the case as made out by the Complainants in the Complaint filed before the District Commission are that the Complainant was account holder of OP No.3. He had obtained Oriental Insurance Bank Saathi Policy No. 233599/48/2022/431 for the year 2021-2022 through OP No.3. Said policy was valid w.e.f. 03.12.2021 to 02.12.2022 as issued by OPs No.1&2. The Complainant had got himself, his wife and his son insured under the said policy. The Complainant had obtained the said policy from the OPs for the year 2014-15, 2015-16, 2016-17. 2017- 18, 2018-19, 2019-20 and 2020-21 which was valid w.e.f. 03.12.2014 FA No.632 of 2024 3 to 02.12.2021. It was averred that the son of the Complainant was admitted in Fortis Escorts Heart Institute and Research Center Limited, Okhla Road, New Delh due to congenital heart disease on 09.03.2022 and discharged on 19.03.2022. After the treatment of his son, the hospital had applied for cashless preauthorization on 01.03.2022 for an approximate amount of Rs.3,77,000/-. The cumulative authorization for an amount of Rs.2.42.250/- was given by OP No.4 after deduction of Rs.1,34,750/-. Thereafter, another enhancement of preauthorization was applied by the said hospital for an amount of Rs.3,79,015/- on 18.03.2022. The cumulative authorization of Rs.3,09,015/- was given by OP No.4 on 18.03.2022 after deduction of Rs.70,000/-. Thereafter, one more enhancement of preauthorization was applied by the said hospital for an amount of Rs.3,94,246/- on 19.3.2022 and cumulative authorization of Rs.3.44,083/- was given by OP No.4 after deduction of Rs.50.163/-. It was further alleged that after treatment the OPs had declined to pay the approved amount without any reason. Finally, an amount of Rs.4,72,660/- was paid by the Complainant with the hospital for the treatment of his son. The Complainant had got issued legal notice dated 11.04.2022 through his counsel to the OPs. However, the OPs had not responded the same. Thus, the act/conduct of OPs tantamounts to be a case of 'deficiency in service' on the part of OPs. Hence, the Complaint was filed by the Complainant by seeking directions to be issued to the OPs to pay an amount of Rs.4,72,660/- along with interest, to pay an amount of Rs.15,000/- as compensation FA No.632 of 2024 4 on account of mental tension and harassment. Further, to pay an amount of Rs.10,000/- as litigation expenses.
4. Upon issuance of notice of the Complaint, OPs No.1&2 had appeared and filed their written reply by raising certain preliminary objections. It was mentioned in the reply that during the policy period the OPs had received cashless claim request (Estimate) for a sum of Rs.3,77,000/- and the same was proceed vide pre- authorization claim No.27637268. After scrutinizing the cashless documents by OPs, the team of panel doctors had raised an internal query vide letter dated 01.03.2022 asking the insured to submit the following documents:
i. To provide duration of the ailment along with first consultation papers or admission advise note-Provide duration of current ailment certify by treating doctor, also provide heart related treatment doctor.
ii. To provide supportive investigation reports/medical records in support to confirm the diagnosis of the son of the Complainant provide confirmatory investigation report in support of diagnosis.
It was admitted that Mr.Shiv Kumar was insured with the answering OPs since 03.12.2014. It was also mentioned in the reply that during the duration of policy period between 03.12.2021 to 02.12.2022, the son of the Complainant Mr. Bhunesh Bansal, 19 year Male, was admitted in Fortis Hospital for treatment of congenital heart disease which required Aortic Valve replacement. It was found that the son of the Complainant was being treated for the said disease since 2007. He underwent Ballon Aortic Valvotomy presented with DOE. The said hospital had raised preauthorization for sum of Rs.3,77,000/-. During FA No.632 of 2024 5 the processing of the said insurance claim the OPs had taken medical opinion from their senior Doctors with regard to the disease suffered by the son of the Complainant. It was found that the said insurance claim was not payable as per Clause 4.2 of the Insurance Policy. It has been mandated by the said Clause if the proposer is suffering or has suffered from any of the diseases at the time of taking the policy as its terms and conditions, whether declared or not declared would be permanently excluded from the policy Coverage. Congenital Aortic valve disease is included in the said list. In view said Clause cashless Pre Authorization was denied as per terms and conditions of the policy. The Complainant had no locus-standi or cause of action to file the. All other averments made in the Complaint were denied and they had prayed for dismissal of the Complaint.
5. OP No.3 had filed its separate written reply by raising certain preliminary objections that the Complainant had got no locus- standi or cause of action to file the Complaint against answering OP. The Complainant had got himself/his wife/his son insured with Oriental Insurance Company Limited and had paid the said premiums to it. OP No.3 was not in the business of Insurance. The role of OP No.3 was only limited to the extent of being the Facilitator/corporate agent. It had merely introduced the parties. The Complaint was filed on baseless grounds and it was unsustainable in law etc. On merits, it was submitted that the Complainant himself had purchased the Insurance Policy from OPs No.1&2. The Complainant had not purchased any alleged policy from OP No.3 and thus the question of submitting any claim form or other documents or rejection of his claim FA No.632 of 2024 6 by the answering OP did not arise. All other allegations were denied and it had prayed for dismissal of the Complaint.
6. OP No.4 had not appeared before the District Commission and was proceeded against ex-parte by the District Commission vide order dated 15.07.2022.
7. By considering the averments made in the Complaint, the Complaint filed by the Complainant was partly allowed vide order dated 05.08.2024 passed by the District Commission. The relevant part of said order is reproduced as under:-
"22. In view of the above discussion, the present complaint is partly allowed against the opposite parties No.1&2 and the opposite parties No.1&2 are directed to pay an amount of Rs.4,72,660/- along with interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties No.1&2 are further directed to pay Rs.5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs.5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of receipt of copy of this order."
8. The Appellants/OP No.1&2 have filed the present Appeal being aggrieved by the order dated 05.08.2024 passed by the District Commission by raising a number of arguments.
9. Mr.Amit Jaiswal, Advocate learned Counsel for the Appellants/OPs No.1&2 has argued on the similar lines as mentioned in the written reply. Learned Counsel has submitted that the Complainant had applied for final cashless pre-authorization for FA No.632 of 2024 7 Rs.3,94,246/- and the authorization of Rs.3,44,083/- was given by the TPA. However, on scrutiny of documents, it was noticed that Bhunesh Bansal was having pre-existing disease at the time when the first policy was purchased by the Complainant. This fact was concealed by the Complainant at the time of obtaining the first policy from the Appellant Company. Therefore, the cashless pre- authorization was denied. Learned Counsel has further submitted that as per Clause 4.2 of the terms and conditions of the policy, any person suffering from congenital heart disease is excluded from policy coverage said Insurance Policy. Moreover, the insurance contracts are the contract of uberrimae fidei. The proposer is duty bound to disclose complete facts at the time of purchase of policy. In the present case there is a deliberate concealment on the part of the Complainant regarding the medical condition of his son Bhunesh Bansal. Thus, the Complainant was rightly denied the pre-authorized amount by the Appellant Company.
10. Learned Counsel has also submitted that the main issue involved in the present case is with regard to concealment at the time of inception of policy. The first policy was purchased by the Complainant by misleading the Appellant Company. The concealment of material fact pertaining to the medical health of a beneficiary vitiates the very contract of insurance and militates against the principle of uberrimae fidei.
11. Further, it has been submitted by learned Counsel for the Appellants that the subsequent renewals of the said policy were FA No.632 of 2024 8 based on the first policy. The Complainant had concealed material facts at the time of obtaining the first policy. The factum of subsequent renewals cannot help him to take the benefit of his own wrong. The effective policy at the time of the surgery is Ex.C-2. All the said policies are available on the software of the Company. Thus the Complainant had indulged in fraudulent concealment of the disease suffered by his son at the time of obtaining the first policy. The District Commission had wrongly relied the judgments which were not applicable in the present case. He has relied upon certain judgments i.e. 1) "Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd.", 2009(4) RCR (Criminal) 546 (SC), 2) "D.Padma Vs. Branch Manager, State Bank of Hyderabad and Ors.", 2023 (2) C.P.R.360 (NC), 3) "Rina Karmakar Vs. LIC of India & Ors.", 2020 (2) C.P.J. 153 (NC), in support of his oral arguments.
12. Mr.Vivek Salathaia, Advocate, learned proxy Counsel for Respondent No.1 has argued on the same averments as mentioned in the Complaint. Learned Counsel has submitted that the Complainant is a policyholder of Oriental Bank Saathi Policy since 2014, which has been continuously renewed till 2022. The policy insured him, his wife and his son Bhunesh Bansal. He has further submitted that despite multiple cashless authorizations being issued by OP No.4 (TPA), the Complainant was denied the approved claim post-treatment. Due to the said denial, the Complainant was compelled to deposit/pay Rs.4,72,660/- to Fortis Escorts Heart Institute for the treatment of his son. The insurer later denied the FA No.632 of 2024 9 claim citing pre-existing congenital heart disease as a ground of exclusion, even though the policy was uninterruptedly renewed for 8 years. No Proposal Form or terms of exclusion were ever provided to the Complainant. It has also been submitted that since the policy had been renewed for several years without any objection or requirement of medical declaration. Therefore, the Insurance Company cannot raise the ground of pre-existing disease subsequently. The insurer had failed to submit the Proposal Form or any document showing that the Complainant was well aware of Clause 4.2. Further, the denial of claim by the OPs amounted to be a case of 'deficiency in service' and 'unfair trade practice'. Learned Counsel has also submitted that the District Commission has passed the well-reasoned order and no interference is required in it. He has relied upon the judgments i.e. 1) Modern Insulator Ltd. Vs. Oriental Insurance Co. Ltd., 2000 (1) CPC 596, 2) Bharat Watch Co. Vs. National Insurance Co. Ltd., (2019) 6 SCC 212 and 3) IFFCO Tokio Gen. Ins. Co. Ltd. Vs. Permanent Lok Adalat (Public Utility Services) & Ors., (P&HHC) 2012 (1) RCR (Civil) 901, in support of his oral arguments.
13. We have heard the oral arguments raised by learned Counsel for the parties in the Appeal. We have also perused the orders dated 05.08.2024 as well as all the relevant documents available on both the files.
14. Facts relating to the filing of the Complaint by the Complainant before the District Commission, issuance of notice, raising of oral arguments by learned Counsel for the parties and FA No.632 of 2024 10 passing of impugned order dated 05.08.2024 by the District Commission, thereafter filing of present Appeal before this Commission by the Appellants/OPs No.1&2 are not in dispute.
15. The issue for adjudication before us as to whether the OPs No.1&2 had rightly repudiated the Insurance Claim of the Complainant for the treatment of his son for congenital heart disease or not?
16. Before adjudicating on the aforesaid issue, it is necessary to define Congenital Heart Disease. As per medical literature "Congenital Heart disease" (CHD) is a birth defect affecting the heart's structure, most commonly involving the heart walls, valves, or large blood vessels.
17. Further, to deal with the aforesaid issue, we have gone through the following documents available on record.
i. Policy Ex.C-2/Ex.OP1.2/1
ii. Bill dated 19.03.2022 Ex.C-3
iii. Bills Ex.C-4 (12 pages)
iv. Authorization letters Ex.C-5 to Ex.C-9
v. Discharge Summary Ex.C-10/Ex.OP1.2/2
vi. Legal Notice dated 11.04.2022 Ex.C-11, postal receipts Ex.C-
12 to Ex.C-15.
vii. Reply dated 28.04.2022 to legal notice Ex.OP1.2/4
viii. Terms and conditions of the policy Ex.OP1.2/5 On perusal of Discharge Summary (Ex.C-10)/sequence of events shows that the son of the Complainant-Bhunesh Bansal, was born on 02.10.2003. He was suspected to be having Congenital Heart Disease at the age of one year. He had undergone Echo investigation FA No.632 of 2024 11 on 05.04.2005 i.e. at the age of 2, there were subsequent Echo tests on 10.08.2006, 24.09.2007, 10.10.2007, 19.03.2008, 12.02.2010, 21.03.2012, 30.12.2013, 28.12.2015, 09.03.2018, 18.02.2019, 06.03.2020, 17.09.2021 and 01.03.2022. In the year 2007, he had undergone Cath and Balloon Aortic Valvotomy on 09.10.2007. Balloon Aortic Valvotomy refers to a procedure which is carried out to widen a narrowed aortic valve. It increases blood flow and relieves symptoms related to heart disease. Meaning thereby the son of Complainant had undergone the said medical procedure at age of approximately 4 years. The Complainant had purchased his first Insurance Policy No.233599/48/2015/234 (Annexure A-3) in the year 2014 when his son was already 11 years of age. The son had his first procedure related to heart disease in the year 2007. Therefore, the Complainant was aware/in knowledge of the medical condition of his son i.e. Congenital Heart Disease. As per Discharge Summary (Ex.C-10), he was suffer from Bicuspid Arotic Valve, Valvular Aortic Stenosis and Trivial Aortic Regurgitation. A bicuspid aortic valve (BAV) is a congenital heart defect where the aortic valve has two leaflets instead of the normal three, which can lead to complications like aortic stenosis (narrowing) or aortic regurgitation (leaking). It is the most common congenital heart defect, affecting about 1-2% of the population, and is present from birth, though it often doesn't cause problems until adulthood. He had undergone regular follow up as mentioned above and was admitted for Aortic Valve replacement on 09.03.2022 (Ex.C-10). FA No.632 of 2024 12
18. A perusal of Annexure A-3 i.e. the policy issued by the Appellant Company shows that under the caption of Pre-Existing Ailments, if any, the Complainant had mentioned 'No' in case of himself, his wife and his dependent child (page 75). The said Insurance Policy was subsequently renewed in the year 2015-16, 2016-17, 2017-18, 2018-19, 2019-20, 2020-21, 2021-22 (page Nos.77 to 95). In the subsequently policies also under the caption of Pre-Existing Ailments, if any, No has been mentioned. It clearly shows that the Complainant inspite of having knowledge of the medical condition/disease of his son with regard Congenital Heart Disease had concealed certain material fact. The subsequent policies were renewed on the basis of the first Insurance Policy obtained by him in the year 2014. Had the Complainant mentioned the fact regarding medical condition of his son, the OPs could have issued him a policy with a higher premium. Therefore, the contention of learned Counsel for the Appellants/OPs No.1&2 that the Complainant cannot be allowed to take benefit of his own wrong/concealment is hereby accepted.
19. Furthermore, we have gone through the Exclusion Clause 4.2 of the terms and conditions wherein under the caption of Heart Ailment at Serial No.4 Congenital Heart Disease and Valvular Heart Disease, whether declared or no declared are permanently excluded. In this context, the learned Counsel for Respondent No.1/Complainant has submitted that no Proposal Form or terms of Exclusion were not provided to him. To verify this factum, we have gone through the contents/averments of the Complaint filed by the FA No.632 of 2024 13 Complainant before the District Commission. It has transpired that the Complainant has nowhere mentioned that he had not received Proposal Form/terms and conditions of the policy containing the Exclusion Clause. In fact he himself had enclosed photocopy of the policy (para 3 (a) of the Complaint). Moreover, the Complainant got his policy renewed for eight years consecutively. It is hard to believe that he was unaware of terms and conditions/exclusion clause from the year 2014-2022. Besides, he failed to inform the OPs No.1&2 with regard to factum of Congenital Heart Disease his son was suffering from.
20. In view of the above mentioned observation, we of the view that Appellants/OPs No.1&2 had rightly denied the pre- authorized amount of the Complainant. The Appellants/OPs No.1&2 had cited in the communication addressed to Administrator/Medical Superintendent, Escorts Heart Institute and Research Centre, Okhla Road, New Delhi, The reason for denial of claim is reproduced below:
We regret to inform you, that we are unable to authorize the Enhancement request for this claim due to the following reasons:
1. Policy since 03.12.2014, 19 year male with congenital heart disease. Admitted due to aortic valve replacement, the member was detected to have congenital heart disease for which he underwent Balloon Aortic Volvotomy in 2007.
Presented with DOE. As per policy-4.2 if the proposer is suffering or has suffered from any of the following diseases at the time of taking the policy, whether declared or not declared, they will be permanently excluded from the policy coverage. Congenital Aortic Valve disease is included in the list provided. Hence, the claim is not payable.
FA No.632 of 2024 14
21. We have also gone through the order passed by the District Commission. It has been observed, the District Commission had failed to appreciate the contents of Discharge Summary as well as the Exclusion Clause mentioned in terms and conditions of the policy. More so it has clearly transpired that the Complainant had concealed the material fact of medical condition of his son while obtaining the policy for the first time from the Appellant Company. Therefore, the Complainant is not entitled for any claim as per the terms and conditions of the Insurance Policy.
22. In light of the above, foregoing discussion in the preceding paras, we find force in the arguments raised by learned Counsel for the Appellants/OPs No.1&2. Accordingly, the Appeal filed by the Appellants/OPs No.1&2 is allowed and the order dated 05.08.2024 passed by the District Commission is set aside.
23. The Appellants had deposited an amount of Rs.2,81,305/- at the time of filing the appeal with this Commission and deposited an amount of Rs.2,82,348/- in compliance of order dated 06.11.2024. Said amount along with interest which has accrued on the amount deposited by the Appellants, if any, shall be remitted by the Registry to the Appellant by way of a crossed cheque/demand draft after the expiry of limitation period in accordance with law.
24. Since the main case has been disposed off, so all the pending miscellaneous applications, if any, are accordingly, disposed off.
FA No.632 of 2024 15
25. The Appeal could not be decided within the statutory period due to heavy pendency of court cases.
(JUSTICE DAYA CHAUDHARY) PRESIDENT (SIMARJOT KAUR) MEMBER (VISHAV KANT GARG) MEMBER November 10, 2025 (Rupinder 2)