IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution : 19.08.2011 Date of Reserving : 10.05.2022 the Order Date of Decision : 05.07.2022 FIRST APPEAL NO - 423/2011 IN THE MATTER OF United India Insurance Company Ltd.

55, Janpath, New Delhi-110001.

(Through: Mr Maibam N. Singh, Advocate)

…Appellant VERSUS Parmod Kumar Sharma R/o A-224, Jhilmil Colony, Shahdara, Delhi-110032 …Respondent (Proceeded ex-parte vide order dated 18.02.2013)

HON’BLE MS. PINKI, MEMBER(JUDICIAL)

HON’BLE MS. BIMLA KUMARI, MEMBER (FEMALE)

Present: Mr Maibam N. Singh advocate learned counsel for the appellant None for the respondent, (proceeded ex-parte vide order dated

18.02.2013)

PINKI, MEMBER (JUDICIAL)

ORDER

1. The present appeal has been filed on 19.08.2011 impugning the order dated 13.06.2011 passed by District Consumer Disputes Redressal Forum (East).

2. The District Forum has directed the appellant/opposite party to pay Rs. 2,00,000/- as well as Rs. 50,000/- as the compensation for mental agony and suffering inclusive of the litigation charges to the complainant/respondent.

3. The submissions put forth by learned counsel for the appellant have been heard and considered. The record before us including that of the District Consumer Redressal Forum East as well as the written submissions filed on behalf of appellant have been carefully perused and considered.

4. The respondent/complainant was proceeded ex-parte vide order dated 18.02.2013.

5. Briefly stating the facts required for deciding this appeal are as under :

The complainant/respondent has purchased Health Shield Insurance Policy from 11.12.2009 to 10.12.2010 for a sum of Rs. 2,00,000/- with Rs. 4,974/- as premium. In the month of February 2010 complainant’s daughter had some problem and she was admitted in St. Stephen’s Hospital on 28.02.2010. She was discharged on 14.04.2010. The complainant had to pay a sum of Rs. 2,08,709/- qua medical bills which were submitted to the appellant/opposite party, however, the opposite party had refused to pay the amount.

6. The case of appellant/opposite party before the District Forum in its written statement was that the insurance company is not liable to make any payment on this policy. It has been submitted that in view of Clause 4.3 during the first two years of the operation of the policy, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia Hydrocele, Congenital Internal Disease, Fistula in Anus, Piles, Sinusitis and related disorders, Gall Bladder Stone Removal, Gout and Rheumatisim, Calculus diseases, Joint Replacement due to Degenerative Condition and age related Osteoarthritis and Osteoporosis are not payable. However, it is admitted that the complainant has claimed a policy.

7. In the appeal the appellant/opposite party has taken grounds inter alia that the impugned order dated 13.06.2011 is based on extraneous grounds, assumption and presumptions ; the District Forum over stretched its limits and entered into deliberations beyond its jurisdiction ; did not take into consideration the submissions and documents made/filed by the appellant/opposite party in the Forum ; it has been passed in total ignorance of well established principles of law and documents ; the District Forum overlooked the fact that the insurance is a contract between the two parties i.e. the insurer and the insured wherein one is making the offer and the other is giving his acceptance to the terms and conditions of the contract mentioned in the policy, which is legally binding on both the parties and nothing outside the purview of the terms and conditions of the policy of the insurance contract would neither be binding on the complainant nor on the opposite party, in other words contract of insurance is legally binding agreement between an insured and insurance company to indemnify the buyer of a contract under specified circumstances ; the insurance company before giving the insurance pol