ADDITIONAL BENCH STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.

First Appeal No.239 of 2020 Date of institution : 05.08.2020 Reserved on : 16.08.2023 Date of decision : 25.08.2023 M/s Star Health and Allied Insurance Co. Ltd., through its branch Manager, SCF 12-13, Improvement Trust Market, above ICICI Bank, G.T.Road, Moga-142001 through its duly constituted attorney.

…..Appellant/Opposite Party No.1 Versus

1. Mohinder Pal, aged 66 years son of Sh. Maghi Ram Goyal, resident of Ward No.1, Near Government High School, Talwandi Bhai, Tehsil and District Ferozepur, Punjab.

….Respondent No.1/complainant

2. Harpreet Singh, Code No.BA0000261983 agent of Star Health and Allied Insurance Company Limited, SCF 12-13, Improvement Trust Market, above ICICI Bank, G.T. Road, Moga 142001.

…..Respondent No.2/OP No.2 First Appeal under Section 41 of the Consumer Protection Act, 1986 against the order dated 14.02.2020 of the District Consumer Disputes Redressal Forum (now ‘Commission’), Ferozepur Quorum:-

Mr. H.P.S. Mahal, Presiding Judicial Member Mrs. Kiran Sibal, Member Argued by:-

For the appellant : Sh. Neeraj Khanna, Advocate for Sh. Ravinder Arora, Advocate For respondent No.1 : Sh. Sandeep Khunger, Advocate For respondent No.2 : Ex-parte KIRAN SIBAL, MEMBER The instant appeal has been filed by the appellant/opposite party No.1 against the impugned order dated 14.02.2020 passed by District Consumer Disputes Redressal Forum, Ferozepur (in short, now “the District Commission”), whereby the complaint filed by complainant against opposite parties (in short ‘OPs’), under Section 12 of the Consumer Protection Act, 1986, was allowed and the following relief has been granted against OP No.1:

“11. In view of what has been discussed above, the present complaint is allowed with Rs.5,000/- as consolidated compensation for mental agony, pain and harassment as well as litigation expenses. Opposite party No.1 is directed to pay the remaining claim of the complainant i.e. Rs.1,62,923/- of first claim and Rs.3,33,700/- of second claim, which spent on his treatment alongwith interest @8% per annum from the date of filing of the complaint till its realization. However, the opposite party No.1 is at liberty to deduct co-payment charges at the rate of 30% out of claim amount as per terms of the policy. Complaint against opposite party No.2 stands dismissed.”

2. It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Commission.

3. Brief facts for the disposal of the appeal are that the complainant was purchasing medi-claim policies of OP No.1 since 2016 and was having a policy bearing No.P/211222/01/2019/000229 valid for the period from 16.05.2018 to 15.05.2019 for the sum assured of Rs.10 lakh. At the time of issuing the policies, no medical check up of the complainant was got conducted by the OPs. Unfortunately, the complainant had to undergo bilateral ‘Total knee replacement’ operation in June 2018 from IVY Hospital Super Speciality Healthcare, Mohali. The complainant spent an amount of Rs.2,82,988/- on the said operation. All the bills along with discharge summary was submitted with OP No.1 and after verifying the same, an amount of Rs.1,20,065/- only was paid by it directly to the hospital and the complainant had to pay the remaining amount of Rs.1,62,923/-, for which he was entitled for refund of the same by OP No.1 under the said policy. It was specifically mentioned on the discharge summary that complainant had a past history of “Rheumatoid Arthritis, though he was not aware about the same. Unfortunately, after about 10 months, the complainant had to undergo a second operation of “Left Hip” total replacement on 17.04.2019 from ‘Medanta, The Medicity Gurgaon’ and an amount of Rs.3,33,700/- had been spent on the said operation. Intimation in this regard was given to OPs, who appointed an investigator and all the bills in original were obtained by the said investigator. Thereafter,