STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.

Date of institution : 13.08.2019 Reserved On : 06.01.2022 Date of decision : 04.02.2022 Dinesh Kumar, aged about 45 years, S/o Sh. Girdhari Lal, resident of Mandi Harji Ram, Malout, District Sri Muktsar Sahib.

….Appellant/Complainant Versus National Insurance Company through its Branch Manager, having its st Branch Office at 1 Floor, LIC Building, Malout-152107, Tehsil Malout, District Sri Muktsar Sahib.

….Respondent/Opposite Party First Appeal under Section 15 of the Consumer Protection Act, 1986 against the order dated 09.07.2019 passed by the District Consumer Disputes Redressal Forum (now, “Commission”) Sri Muktsar Sahib.

Quorum:-

Hon’ble Mrs. Justice Daya Chaudhary, President Mrs. Urvashi Agnihotri, Member.

1) Whether Reporters of the Newspapers may be allowed to see the Judgment? Yes/No

2) To be referred to the Reporters or not? Yes/No

3) Whether judgment should be reported in the Digest? Yes/No Argued By:-

For the appellant : Sh. S.K. Verma, Advocate For the respondent : Sh. Satpal Dhamija, Advocate.

JUSTICE DAYA CHAUDHARY, PRESIDENT The appellant/complainant-Dinesh Kumar is aggrieved by the impugned order dated 09.07.2019 passed by the District Consumer Disputes Redressal Forum (now, “Commission”), Sri Muktsar Sahib (in short, “the District Commission”), whereby the Complaint Consumer bearing No.87 of 2018 filed by him was dismissed.

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

3. Briefly, the facts of the case as made out in the complaint are that the complainant purchased Insurance Policy bearing No.40100648168585000000162 from the respondent/opposite party for the period 03.09.2016 to 02.09.2017 for a sum assured of ₹4,00,000/- by paying a premium of ₹19,472/- vide receipt dated 05.09.2016. The complainant was assured that all illnesses and diseases occurred during that period would be covered under the said policy and he would be entitled for mediclaim expenses incurred on the treatment.

4. The complainant suffered problem of blood in the stool on 04.08.2017 and got treatment from Dr. Jaswinder Singh of Dayanand Medical College & Hospital (in short, “DMC”), Ludhiana. He remained admitted in the said hospital from 04.08.2017 to 16.08.2017 and spent an amount of ₹3,00,000/- on his treatment, medicines, tests etc. It was further mentioned that the complainant never consumed alcohol and used cigarette and other intoxicated material and he was totally non- smoker and non-alcoholic. While submitting his claim to the respondent/opposite party, all the required documents for reimbursement of medical expenses were supplied. The claim of the appellant/complainant was rejected by the respondent/opposite party vide letter dated 10.10.2017, stating that the same was not payable as per provisions of Clause 4.21 of the policy. The respondent/opposite party contested the complaint by filing reply thereto.

5. The said complaint filed by the complainant was dismissed by the District Commission, vide passing detailed impugned order dated 09.07.2019. The relevant portion of the impugned order as mentioned in Paras 11 and 12 is reproduced as under:

“11. CW-2 Hakam Singh is only a Record Keeper and his evidence is not as useful as the evidence of Dr. Jaswinder Singh who treated the patient but complainant has not summoned Dr. Jaswinder Singh for evidence in the Forum. Only Dr. Jaswinder Singh could tell the actual condition of the complainant. Furthermore, as per Ex.C-4 i.e. Discharge Summary, complainant was diagnosed as Obesity and OSA and Anemia. As per clause 4.9 of the Policy, treatment for obesity or condition arising there from and any other weight control and management program are totally excluded under the Policy and as per clause 4.21 of the policy, treatment arising out of illness/disease/injury due to misuse or abuse of drugs/alcohol or use of intoxicating substances are also totally