IMPORTANT POINT
Contract of insurance – Since the policy was held/renewed for 5 years, the plea of non-supply of terms and conditions is not tenable; the insured should have agitated this earlier.

JUDGMENT

Vishav Kant Garg, Member.—Insurance Co., has filed the present Appeal through its Authorized Representative to challenge the impugned order dated 24.02.2025 passed by the District Consumer Disputes Redressal Commission, Barnala (in short, “the District Commission”), whereby the Complaint filed by the Respondents Nos.1 and 2/Complainants-Raj Kumar Rattan & Anr. 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 Respondents Nos.1 and 2/Complainants in the Complaint filed before the District Commission are that the Complainants had purchased PNB-Oriental Mediclaim Group Health Insurance Policy, valid for the period w.e.f. 28.02.2022 to 27.02.2023, having floater basic sum insured of Rs.5,00,000/-, on paying premium of Rs.34,890/-. They had purchased the first policy in the year 2018 and there was no break till that. At the time of issuance of the policy, the medical check-up of the Complainant No.1, his wife and daughter was done.

4. It was averred that Complainant No.2 had suffered the problem of Ruq Pain, Nausea, Vomiting, H/o Fever and remained admitted with OP No.3 Hospital on 20.12.2022. She was discharged from the said Hospital on 23.12.2022. The Doctor of the said Hospital had informed that there was stone in the Gal Bladder of the patient. Intimation regarding admission was given to the Insurance Company and they had assured that the Complainants were not to pay anything to OP No.3 for the treatment. Due to said problem, Laproscopic Cholecystectomy surgery of the Complainant No.2 was done by Dr. Rajinder Kumar on 21.12.2022. OP No.3 had raised the bill of Rs.1,50,639/- regarding the treatment but the Insurance Co. had paid only Rs.30,000/- against the said treatment. Due to this, the Complainants had to pay the remaining amount of Rs.1,20,639/- from their own pocket by paying Rs.5,000/- and Rs.95,000/-. Thereafter, the Complainants had lodged the Complaint with Ombudsman, Chandigarh and the said Authority had directed the Insurance Company to reassess the claim and pay the balance amount within 30 days.

5. Stating the act of the OP-Insurance Co. to be a case of ‘deficiency in service’ and ‘unfair trade practice’, it was prayed in the Complaint that the OPs be directed to pay Rs.1,00,000/- the remaining treatment charges paid by the Complainants along with 18% p.a. interest from the date of discharge till realization. Rs.3,00,000/- be demanded on account of mental agony and harassment suffered due to illegal act of the OPs and Rs.33,000/- as litigation expenses.

6. Upon issuance of notice in the Complaint, the Appellant/OP No.1 had filed the written statement by raising certain preliminary objections that the Complainants had no cause of action to file the Complaint. The Complainants had not approached the Commission with clean hands. Issuance of the Insurance Policy and submission of the claim during the inception of the policy was an admitted fact. The claim of the Complainants had been assessed as per terms and conditions of the Insurance Policy. There was capping of Rs.30,000/- under Sub Clause 6 of Clause No.2.17 in the Policy for the treatment of Appendicitis, Gall Bladder Stones under Plan A. Therefore, against the claim of Rs.1,49,663/- an amount of Rs.29,700/- had been sanctioned. As per Insurance Ombudsman Award dated 29.03.2023, the claim had been re- assessed and found that the same had been rightly settled. There was no ‘deficiency in service’ or ‘unfair trade practice’ in settling the claim as per terms and conditions of the policy. The Complainants had no grievance to file the Complaint but they had challenged the settlement of OP No.1 unnecessarily, without any reason. It was prayed that the Complaint, being without merit be dismissed.

7. After considering the contents of the Complaint and the reply thereof filed by the Opposite Parties as well