ORIENTAL INSURANCE COMPANY LIMITED Vs. PERMANENT LOK ADALAT

JUDGEMENT

(1.) The petitioner through instant petition under Article 226 of the Constitution of India is seeking setting aside of award dtd. 20/7/2023 (Annexure P-6) passed by learned Permanent Lok Adalat (Public Utility Services) Patiala (for short "PLA") whereby claim of respondent No. 2 has been allowed.

(2.) The respondent-insured purchased an insurance policy from petitioner-insurer. He paid premium of Rs.6960.00. The sum assured was Rs.5,00,000.00. The respondent-insured on the basis of policy lodged claim. The petitioner examined the matter and formed an opinion that there was suppression of facts, thus, claim is liable to be repudiated. Accordingly, petitioner rejected his claim. The respondent-insured filed an application under Sec. 22C of 1987 Act before Ld. PLA which sought response of the petitioner. Matter was tried to be reconciled, however, was finally adjudicated on merits. Ld. PLA has concluded that there was no occasion to repudiate applicant's claim, thus, petitioner has wrongly rejected the same.

(3.) Learned counsel for the petitioner submits that respondent-insured was suffering from heart disease. He suffered heard attack in 1994 and got treatment. The disease of respondent-insured fell within the purview of pre-existing disease and as per Clause 4.1 of the Policy, reimbursement is not permissible with respect to pre-existing disease up to 36 months of the Policy. The respondent-insured purchased Policy on 28/5/2016 and suffered heart attack on 29/1/2017 means within 36 months from the date of Policy. In the wake of exclusion clause, the respondent-insured was not entitled to reimbursement of medical expenses.