STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.

Date of institution : 30.04.2025 Reserved on : 11.12.2025 Date of Decision : 05.01.2026 M/s Oriental Insurance Co., 4501, 1^st and 2^nd Floor, Bank Bazar, Bathinda-151 001 through Manager, Appellant now through their Authorized Representative/POA Holder/GPA Holder Mr. Sumeet Raval, Dy. Manager RO, The Oriental Insurance Company Ltd., Regional Office, SCO 109-111, Surindra Building, Sector 17C, Chandigarh …Appellant/Opposite Party No.1 Versus

1. Raj Kumar Rattan S/o Sh. Bawa Dutt Rattan, Resident of B-XI- 2729, Aman Street, Near M.C. Office, Barnala, District Barnala, Punjab-148101

2. Saroj Rani wife of Raj Kumar Rattan S/o Sh. Bawa Dutt Rattan, resident of B-XI-2729, Aman Street, Near M.C. Office, Barnala, District Barnala, Punjab-148101 .…Respondents No.1&2/Complainants

3. M/s Medi Assist Insurance TPA, No. 4/1, IBC Knowledge Park, Tower D, 4^th Floor, Bannerghatta Road, Bangalore-560029 through Manager

4. Manipal Hospitals, Bhupindra Road, Near 22 No. Phatak, Patiala – 147001 through Manager.

.…Respondents No.3&4/OPs No.2&3 First Appeal under Section 41 of the Consumer Protection Act, 2019 against the order dated 24.02.2025 passed by the District Consumer Disputes Redressal Commission, Barnala in C.C. No. 99 of 2023.

Quorum:-

Hon’ble Mrs. Justice Daya Chaudhary, President Ms. Simarjot Kaur, Member Mr. Vishav Kant Garg, 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. Arjun Kundra, Advocate For respondents No.1&2 : Sh. Hitesh Verma, Advocate (Through VC)

For respondent No.3 : Sh. Bhupender Singh, Advocate (Through VC)

For respondent No.4 : None VISHAV KANT GARG, MEMBER :

Appellant/Opposite Party No.1 i.e. M/s Oriental Insurance Co., has filed the present Appeal through its Authorized Representative to challenge the impugned order dated 24.02.2025 passed by the District Consumer Disputes Redressal Commission, Barnala (in short, “the District Commission”), whereby the Complaint filed by the Respondents No.1&2/Complainants-Raj Kumar Rattan & Anr. had been partly allowed.

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

3. Briefly, the facts of the case as made out by the Respondents No.1&2/Complainants in the Complaint filed before the District Commission are that the Complainants had purchased PNB-Oriental Mediclaim Group Health Insurance Policy, valid for the period w.e.f. 28.02.2022 to 27.02.2023, having floater basic sum insured of Rs.5,00,000/-, on paying premium of Rs.34,890/-. They had purchased the first policy in the year 2018 and there was no break till that. At the time of issuance of the policy, the medical check-up of the Complainant No.1, his wife and daughter was done.

4. It was averred that Complainant No. 2 had suffered the problem of Ruq Pain, Nausea, Vomiting, H/o Fever and remained admitted with OP No.3 Hospital on 20.12.2022. She was discharged from the said Hospital on 23.12.2022. The Doctor of the said Hospital had informed that there was stone in the Gal Bladder of the patient. Intimation regarding admission was given to the Insurance Company and they had assured that the Complainants were not to pay anything to OP No.3 for the treatment. Due to said problem, Laproscopic Cholecystectomy surgery of the Complainant No.2 was done by Dr. Rajinder Kumar on 21.12.2022. OP No. 3 had raised the bill of Rs.1,50,639/- regarding the treatment but the Insurance Co. had paid only Rs.30,000/- against the said treatment. Due to this, the Complainants had to pay the remaining amount of Rs.1,20,639/- from their own pocket by paying Rs.5,000/- and Rs.95,000/-. Thereafter, the Complainants had lodged the Complaint with Ombudsman, Chandigarh and the said Authority had directed the Insurance Company to reassess th