ORDER

( 15.06.2023 ) The following order of the Bench was delivered by Shri A.K. Tiwari, Member.

This appeal by the appellants/opposite parties is directed against the order dated 25.9.2020, passed by the District Consumer Disputes Redressal Commission, Shivpuri (for short ‘District Commission’), in complaint case No. 132/2019, whereby the District Commission has allowed the complaint filed by the complainant/respondent.

2. Briefly put, the facts of the case are that the respondent/compliant had obtained a Health Insurance Policy from appellants-Insurance Company in the year 2008. The Insurance Company assured that the respondent-complainant will get the facility of treatment from any hospital and the Insurance Company will indemnify the expenses incurred by the respondent within 15 days of discharge from the hospital, in some selected hospitals, benefit cashless policy was also available. In the year 2014, the respondent/complainant underwent a surgery for implant of artificial heart valve in Apollo Hospital, Delhi. The appellants-Insurance Company accepted the claim for the said surgery and by extending facility of cashless policy, paid Rs.1,00.000/- to the her. The respondent developed some complications after surgery of artificial heart valve implantation and she visited the doctors at Indore and Delhi, who referred her to M.N. Hospital Chennai, for expert opinion and further treatment, where she got admitted on 22nd November, 2016 from where she informed the appellants/Insurance Company about her health condition and sought cashless approval for her treatment. The appellants/Insurance Company refused cashless approval on the ground that the treatment sought by the respondent was of a disease of congenital in nature, which is not covered under the policy and rejected her claim for cashless approval.

Aggrieved by the refusal of her claim, the respondent/complainant approached the District Commission by filing the aforesaid complaint which was allowed.

3. The appellants/opposite parties have filed reply before the District Commission and submitted that the complainant took treatment and underwent a surgery for heart ailments from G.B. Pant Hospital, New Delhi in the year 1993. According to the discharge summary issued by the said Hospital the disease with which the complainant was suffering, was congenital in nature. Therefore, when complainant informed about treatment at Madras Medical Mission Hospital she was informed vide letter dated 27.11.2018 that her ailment is not covered as per policy’s permanent exclusion clause 3.3.11 and rejected her request. The opposite parties, therefore, sought dismissal of the complaint.

4. The District Commission allowed the complaint with compensation cost.

5. Learned counsel for appellants submits that it is undisputed that the respondent/complainant took treatment from G.B. Pant Hospital, New Delhi, in the year 1993 and it is also clear from the discharge summary issued by this hospital that the respondent was suffering with congenital disease. She further submits that the pre-approval sought by the respondent/ complainant for treatment at Medical Mission Hospital was rejected on this ground. Learned counsel for appellants, therefore, submits that there in no deficiency in service on the part of appellants/Insurance Company. The order passed by the District Commission is erroneous and liable to be set aside and the appeal filed by the appellants may be allowed.

6. Respondent, who is present in person, submits that she had obtained the health insurance policy in the year 2008 and the appellants/Insurance Company renewed the policy regularly, on payment of annual premiums by her. She further submits that while obtaining the policy she has informed the Insurance Company about her health issues and about her open heart surgery in t