IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution: 29.01.2024 Date of Hearing: 09.01.2026 Date of Decision: 27.01.2026 FIRST APPEAL NO.- 65/2024 IN THE MATTER OF NATIONAL INSURANCE CO. LTD., 2E/9, JHANDEWALA EXTENSION, NEW DELHI-110055.

(Through Mr. S. K. Pandey, Advocate)

…Appellant VERSUS MR. BHAWESH ANAND, S/O LATE SH. RAM PREM PRAKASH ANAND, M-11, SAKET, NEW DELHI-110017.

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(Through: Mr. Lalit Bhati, Advocate)

…Respondent CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

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

Present: Mr. S. K. Pandey and Mr. Shankar Dev, counsel for the Appellant.

Proxy counsel appeared for Mr. Lalit Bhati, counsel for the Respondent.

PER: HON’BLE JUSTICE SANGITA DHINGRA SEHGAL PRESIDENT JUDGMENT

1. The facts of the case as per the District Commission record are:

“The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986. The brief details of facts, as alleged by the Complainant in the Complaint in hand, are that the complainant has taken the insurance policy no. 361503501710000820 namely "NATIONAL PARIVAR MEDICLAIM POLICY" for sum assured of Rs. 5,00,000/- on payment of premium of Rs. 27,126/- which was effective from 15.03.2018 to midnight of 14.03.2019 (Both days inclusive) from the OP-1. The copy of policy documents are annexed with the complaint as Annexure A-2. It is further stated that on 28.03.2018, the complainant got severe heart attack and got admitted in emergency at Max Super Specialty Hospital, Saket for his immediate treatment. The complainant intimated the opposite party-1 under the prescribed time which the opposite party no. 1 forwarded to its designated third party i.e. opposite party no. 2 (which was never disclosed/ mentioned to the complainant) at time of issuing policy. A copy of discharged summary has been annexed with complaint as Annexure A-3.

2. It has further been alleged that cashless treatment was denied by the OP-1 and complainant paid the treatment expenses to the hospital through his own arrangement to get discharged on 31.03.2018 from mediclaim policy. Thereafter, the complainant had submitted claim for reimbursement of expenses to the opposite party on 12.09.2018. A copy of claim form has been annexed as Annexure A-4 alongwith the complaint. It has been alleged that the opposite parties have failed to make the payment to the complainant till date. A copy of medical bills has been annexed as Annexure A-5.

3. It is further alleged that on 3.10.2018, opposite parties denied to make the payment of medical expenditure through email dated 03-10-2018 which has been annexed as Annexure A-6 with the complaint. Thereafter, the complainant has made many requests to the opposite party but the opposite party has not paid any heed and proper attention on the request of the complainant. The complainant has also sent two legal notices dated 4.05.2019 and 22.05.2019 to the opposite party which was duly served upon the Opposite Parties but the opposite party has not responded. A copy of the Legal Notices has been annexed as Annexure A-7 (04.05.2019) and Annexure A-8 (22.05.2019) with the complaint. The complainant has stated that he is legally entitled to recover the amount spent during treatment but the opposite party have raised false and baseless objection to avoid its liability to make the payment against the medical treatment of the complainant.

Therefore, this complaint has been filed praying for directions to OPs to:-

a. pay the claim amount of Rs. 2,32,489/- alongwith interest @

18% per annum till realization;

b) Pay Rs. 2,00,000/- to the complainant on account of deficiency of service, mental tension, pain and suffering;

c) Grant litigation expenses Rs. 55,000/-;

d) Any other or further relief which this Hon'ble court deem fit and proper in the facts and circumstances of the case

4. Accordingly, notices were issued to the OPs and in response, the OP1 has filed reply whereas the OP-2 (TPA) did not participate in the proceedings. S