STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA FIRST APPEAL NO. SC/6/A/1583/2017 M/S STAR HEALTH AND ALLIED INSURANCE COMPANY LTD.

PRESENT ADDRESS - 8th FLOOR, PALM COURT, MAHARAN PRATAP CHOWK, MEHRAULI ROAD, GURGAON. ,HARYANA.

.......Appellant(s)

Versus NARESH KUMAR GUPTA PRESENT ADDRESS - H.NO. 117-A, NEW COLONY, GURGAON. ,HARYANA.

.......Respondent(s)

BEFORE:

MR. S . P . SOOD , JUDICIAL MEMBER MR. SURESH CHANDER KAUSHIK , MEMBER FOR THE APPELLANT:

MR. SANDEEP SINGH JOSAN, COUNSEL FOR THE APPELLANT.

FOR THE RESPONDENT:

MR. TANMOY GUPTA, COUNSEL FOR RESPONDENT.

DATED: 13/01/2026

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA Date of Institution: 21.12.2017 Date of final hearing: 13.01.2026 Date of order: 13.01.2026 First Appeal No.1583 of 2017 IN THE MATTER OF:-

M/s Star Health and Allied Insurance Company Ltd. through its Branch Manager, 8^th Floor, Palm Court, Maharan Pratap Chowk, Mehrauli Road, Gurgaon-122001, Haryana.

...Appellant Versus Naresh Kumar Gupta deceased through his LRs Smt. Pushpa Gupta W/o Late Sh. Naresh Kumar Gupta, R/o Old Anaj Mandi Tauru at present H. No. 117-A, New Colony, Gurgaon.

...Respondent CORAM: SH. S.P. SOOD, JUDICIAL MEMBER.

SH. S.C. KAUSHIK, MEMBER Present:- Mr. Sandeep Singh Josan, counsel for the appellant.

Mr. Tanmoy Gupta, counsel for respondent.

ORDER

PER: S.P. SOOD, JUDICIAL MEMBER:-

Delay of 18 days in filing of present appeal stands condoned for the reasons mentioned in application seeking condonation of delay.

2. In present appeal No.1583 of 2017; legality of order dated 24.10.2017 passed by learned District Consumer Disputes Redressal Forum, Gurgaon (In short “District Consumer Commission”) in complaint case No.276 of 2016, which was allowed.

3. Factual Matrix: Complainant (now deceased) purchased medi-claim insurance policy from Reliance General Insurance Company on 21.10.2007 and valid from 31.10.2014 to 30.10.2015, which was subsequently renewed for the period from 31.10.2015 to 30.10.2016 for insured sum of Rs.5,00,000/-. Thereafter complainant obtained floater top-up medi-claim policy for insured sum of Rs.10,00,000/- from OP in the year 2012, which was renewed w.e.f. 08.10.2014 to 07.10.2015 over and above the insured sum of Rs. 5,00,000/-. Complainant was hospitalized and admitted in Max Super Specialty Hospital, New Delhi w.e.f. 22.07.2015 to 05.08 2015 and bill of Rs.7,55,921/- was issued by the hospital. Reliance General Insurance Co. paid Rs.2,97,330/- only and the balance amount of Rs.4,25,555/- was paid by complainant to the hospital as OP has not paid the same. Complainant also incurred expenses Rs.60.808/- and thus total sum of Rs.4,86,363/- was liable to be reimbursed by the OP but the claim of complainant (deceased) was repudiated vide letter dated 30.12.2015. The complainant was again hospitalized in the same hospital from 12.09.2015 to 21.09.2015 and bill of Rs.6,98,518/- and Rs.1,20,580/- were paid by complainant. Complainant lodged his claim of Rs.8,19,098/- and submitted all the relevant documents but his claim was repudiated vide letter dated 02.11.2015. As such, OP has got the liability to reimburse Rs.4.96,363/- plus Rs.8,19,098/- total Rs.13,05,463/- but the insured liability was to the extent of Rs.10,00,000/-. The same has been wrongly repudiated vide letter dated 31.10.2015 and 02.11.2015 on the ground that the complainant was a known case of diabetes, hypertension and biliary pancreatitis patient, whereas complainant was not aware about the same in the year 2007 when the policy was taken or in the year 2012 when the medi-claim floater policy was taken.

His claim has been wrongly rejected by OP without any documentary evidence.

4. Upon notice, OP raised contest. In its defense, it is submitted that in respect of claim No. 110808 the insured was admitted in Max Super Speciality Hospital on

22.07.2015 for the treatment of renal allograft recipient and the insured was again admitted in Max Hospital on 12.09.2015 for the treatment of fracture Right ac