IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution: 08.08.2022 Date of Hearing: 02.07.2024 Date of Decision: 06.09.2024 FIRST APPEAL NO-134/2022 IN THE MATTER OF MR. AJAY GUPTA R/O A-84, SURAJ MAL VIHAR, DELHI-110093 …APPELLANT (Through: Ms. Sarita Pandey, Advocate, Mob.9205174429 &

Email: sarita@tclindia.in)

VERSUS STAR HEALTH AND ALLIED INSURANCE CO. LTD., A COMPANY INCORPORATED UNDER THE COMPANIES ACT HAVING ITS OFFICE AT

209/210, LAXMI DEEP BUILDING, DISTRICT CENTRE, LAXMI NAGAR, DELHI-110092 ALSO AT:

1ST FLOOR, HIMALAYA HOUSE, 23, KASTURBA GANDHI MARG, NEW DELHI-110001 ALSO AT:

1, NEW TANK STREET, VALLUVARKOTTAM HIGH ROAD, NUNGAMBAKKAM, CHENNAI-600034 ….RESPONDENT (Through: Mr. Naveen Pandey, Advocate, Mob. 9968893528 &

Email: advnaveen2468@gmail.com)

CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

HON’BLE MS. PINKI, MEMBER (JUDICIAL)

Present: Ms. Anushka Bhatnagar, counsel for the Appellant.

(Mob.9958183837 & Email: anushka@tclindia.in)

Mr. Naveen Pandey, counsel for the Respondent Mob. 9968893528&Email:advnaveen2468@gmail.com PER : HON’BLE PINKI, MEMBER (JUDICIAL)

JUDGMENT

1. The facts of the case as per the District Commission record are as under:

“The Complainant in his complaint has contended that he alongwith his wife Smt. Rashmi Gupta were having Medi-claim Policy from New India Assurance Company for a sum of Rs.2,50,000/- since 2005 with no claim record. In 2015 the Complainant ported his Policy to OP for the period 5.9.2017 to 4.9.2018 (Policy No. P/161111/01/2018/007946) for a sum of Rs.5,00,000/-. As per Circular no. IRDA/HLD/MISC/CIR/030/02/2011 dated 10.2.2011 issued by IRDA the OP is liable to extend the benefits of No claim/pre-existing diseases with the previous Insurance Company. At the time of portability of the Policy neither the Complainant nor his wife suffered from any disease which could have been disclosed. However, the wife of the Complainant had earlier visited GTB Hospital, Delhi on 1.8.2017 with complaint of pain and scratching of left breast for which she was prescribed an ointment and advised Mammography and Ultrasound. The Ultrasound was carried out next day from a Private Lab whose Report dated 3.8.2017 stated ‘nothing abnormal found’. In the last week of November 2017, wife of Complainant felt discomfort in her left breast and visited Max Super-Specialty Hospital, Vaishali on 1.12.2017. She was advised to undergo biopsy wherein she was diagnosed with Breast Cancer and was advised immediate surgery. Without wasting any time, wife of Complainant underwent surgery at Rajiv Gandhi Cancer and Research Institute, Rohini and she remained in that Hospital from 07.12.2017 to 9.12.2017. Pre-approval of cashless facility was requested by Complainant on 7.12.2017 which was denied by OP. The Complainant spent Rs.6,14,610/- towards the treatment of his wife for above said period. However, the claim of the Complainant was rejected by the OP vide letter dated 12.12.2017 and OP also cancelled their Policy and refunded an amount of Rs.11,634/- to Complainant. The main reason of rejection of the claim is breach of Condition 9 and 14 of Policy issued by the OP. The Complainant alleged deficiency in service on the part of OP and sought directions to OP to refund Rs.5,00,000/- alongwith interest @12% p.a. and Rs.5,00,000/- as damages for mental harassment.”

2. The District Commission after taking into consideration the material available on record passed the judgment dated

08.06.2022, whereby it held as follows:

“It is also worth observing that the Complainant’s wife went for consultation in GTB Hospital on 01.8.2017 in surgery department and after getting done USG the Mediclaim policy was ported to OP on 5.9.2017 from the previous insurer/New India Assurance Company Ltd. where the policy was for Rs.2,50,000/- which was enhanced to Rs.5,00,000/- . There is no explanation from the Complainant as to why the amount was suddenly enhanced when there was no medical problem. Complainant has also n