ORDER

1. For the reasons stated therein, the miscellaneous application is allowed and the delay in filing of the appeal is condoned. Page 2 of 5

2. The appellant/opposite party No.2 i.e. Star Health and Allied Insurance Company Limited (insurance company) is in appeal against the order dated 16.11.2023 passed by the District Consumer Disputes Redressal Commission, Sirsa, whereby complaint filed by complainant Darshan Kumar Singla was allowed and opposite party No.2 directed to pay the claim amount of Rs.3,29,775/- to the complainant within a period of 45 days from the date of receipt of the order failing which complainant would be entitled to receive the said amount of Rs.3,29,775/- from opposite party No.2 along with interest @ 6% per annum from the date of the order till actual payment besides Rs.10,000/- as compensation for harassment and Rs.5,000/-

as litigation expenses were also awarded to the complainant.

3. The brief facts of the case are that the complainant had purchased a cashless mediclaim policy for himself and his wife, namely, Ms. Savita Singla from the insurance company through opposite party No.1 i.e. Sh. Hemant Kumar, Agent, for the floater sum insured of Rs.5,00,000/- in the year 2015 and got renewed the same in the years 2016 and 2017 as well as in the year 2018. While taking the policy for the first time i.e. in the year 2015, the complainant was thoroughly checked up by the Inderprastha Hospital, Delhi and all the reports were found negative. Thereafter, while renewing the policy for the period 31.03.2018 to 30.03.2019, the complainant disclosed his existing disease i.e. prostate and its complications and his wife disclosed disease related to female genital system and its complications. In the month of June, 2018, the complainant suffered STAR HEALTH AND ALLIED INSURANCE CO. LTD. VS. DARSHAN KUMAR SINGLA & ANR. Page 3 of 5 heart attack and his coronary angioplasty was got done at Fortis Hospital in Mohali. The complainant remained admitted there from 20.06.2018 to 22.06.2018. The hospital charged Rs.3,43,087/- from the complainant against the hospitalization and treatment. The pre-authorization of the payment of bills was rejected by the opposite parties. After discharge from the hospital, the complainant lodged the claim with the insurance company but the same was also repudiated vide letter dated 14.07.2018. Thus, there was deficiency in service on the part of the opposite parties. Hence, the present complaint.

4. Upon notice, opposite party No.1 did not appear and was proceeded against ex parte. Opposite party No.2 i.e. insurance company appeared and filed its written version stating therein that as per waiting period 3(iii) of the policy, the insurance company was not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition until 48 months of continuous coverage had elapsed since the date of commencement of the first year policy. In case, it is found that the insurance company was liable to pay the claim, the maximum quantum of liability under the terms of the policy would be Rs.3,29,775/- on submission of original discharge summary but no original final bill nor original payment receipt was provided. Other allegations were also denied and a prayer for dismissal of the complaint was made.

5. The complainant as well as the insurance company led their respective evidence in support of their pleas. Page 4 of 5

6. The State Commission has heard counsel for the insurance company and perused the documents attached with the appeal.

7. Indisputably, the complainant had purchased the policy in question and got renewed the same for the period 31.03.2018 to 30.03.2019. Prior to the purchase of the policy, all the necessary tests of the insured were got done and no kind of abnormality was found. There is nothing on record to show that the insured was