STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.

Date of institution : 15.02.2022 Reserved On : 13.09.2022 Date of decision : 06.10.2022 National Insurance Company Limited, Divisional Office Madan Building, Phagwara Road, Hoshiarpur, through its duly Authorized Officer, Regional Office, SCO No.332-334, Sector 34-A, Chandigarh.

….Appellant/Opposite Party Versus Sudha Gupta W/o Sh. Subhash Chander, resident of B-12/360, Bansan Wali Gali, Hoshiarpur.

….Respondent/Complainant First Appeal under Section 41 of the Consumer Protection Act, 2019 against the order dated 20.12.2021 passed by the District Consumer Disputes Redressal Commission, Hoshiarpur.

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 Present:-

For the appellant : Sh. Vinod Gupta, Advocate For the respondent : Sh. Munish Gupta, Advocate.

JUSTICE DAYA CHAUDHARY, PRESIDENT Appellant/opposite party i.e. National Insurance Company Limited has approached this Commission by way of filing the present appeal under Section 41 of the Consumer Protection Act, 2019 against the order dated 20.12.2021 passed by the District Consumer Disputes Redressal Commission, Hoshiarpur (in short, “the District Commission”), whereby the complaint filed by the respondent/ complainant namely Sudha Gupta was partly allowed and the opposite party was directed to pay to the complainant an amount of ₹3,23,359.83 (rounded off to ₹3,23,360/-) along with interest at the rate of 9% per annum from the date of repudiation i.e. 17.03.2020 till its realization along with an amount of ₹20,000/- towards compensation and ₹10,000/- as litigation expenses. The amount so awarded was directed to be paid within a period of 45 days from the date of receipt of certified copy of the order.

2. It would be apposite to mention here 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 by the complainant Sudha Gupta in the complaint filed before the District Commission are that she had been purchasing a ‘BOI National Swasthya Bima Policy’ from the opposite party for herself for the last a number of years. The complainant got her policy renewed in the year 2018 and thereafter in lieu thereof, she paid the requisite premium of ₹7,434/- and policy No.401800501810000053 was issued for the period w.e.f. 18.08.2018 to 17.08.2019 for a sum assured of ₹5 lac. It was further mentioned in the complaint that during the subsistence of said policy, the opposite party undertook to indemnify the complainant being insured for hospitalization charges, post-hospitalization charges as well as other ancillary charges to the tune of ₹5 lac in case she remained hospitalized. The complainant was medically examined by the doctors of the opposite party prior to issuance of the first policy and the opposite party was satisfied with her medical condition. However, during the subsistence of said policy, the complainant suddenly developed chest pain and got admitted herself in Ivy Hospital, Hoshiarpur on 07.06.2019 and thereafter she was taken to Dayanand Medical College (DMC) & Hospital, Ludhiana on the same day, where she remained admitted up to 17.06.2019. However, during her treatment, she underwent Coronary Artery Bypass Grafting (CABG). As per the terms and conditions of the policy, she was not required to pay the hospitalization charges from her own pocket but still her request for cashless facility was not accepted. The opposite party through its TPA expressed its inability to provide cashless treatment vide letter dated 12.06.2019 on the ground that it was not admissible under the ‘Waiting Period’ Clause as it was a known case of Diabetes Mellitus-2 (DM-2) and Hypertension (HTN). The complainant had to spend the entire