STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.

Date of institution : 24.11.2021 Reserved on : 11.12.2024 Date of Decision : 03.01.2025 Akhil Aggarwal son of Sh. Sudhir Aggarwal, B-II/149, 150, Adarsh Nagar, Near Shiv Mandir, Kapurthala, Punjab-144601 ….Appellant/Complainant Versus

1. Max Bupa Health Ins. Co. Ltd., 3^rd Floor, Kunal Towers, The Mall, Ludhiana-141001

2. Max Bupa Health Ins. Co. Ltd., B1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110014, through its Managing Director

3. Max Bupa Health Ins. Co. Ltd., Registered Office at Max House-1, Dr. Jha Marg Okhla, New Delhi-110020.

4. Gaurva Tandon, Agent Max Bupa Health Ins. Co. Ltd., resident of 1620, Phase-1, U.E. Dugri, Ludhiana-141001 .…Respondents/Opposite Parties First Appeal under Section 41 of the Consumer Protection Act, 2019 against the order dated 24.09.2021 passed by the District Consumer Disputes Redressal Commission, Ludhiana. Quorum:-

Hon’ble Mrs. Justice Daya Chaudhary, President 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 : Ms. Sanya Kapoor, Advocate for Sh. Lalit Goyal, Advocate For respondents No.1-3 : Sh. K.S. Cheema, Advocate For respondent No.4 : None VISHAV KANT GARG, MEMBER :

Appellant/Complainant-Akhil Aggarwal has filed the present Appeal to challenge the impugned order dated 24.09.2021 passed by the District Consumer Disputes Redressal Commission, Ludhiana (in short, “the District Commission”), whereby the Complaint filed by the Appellant/Complainant had been dismissed.

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 Appellant/Complainant in the Complaint filed before the District Commission are that he had purchased Family First Silver Policy No. 30334460201400 of the OP, covering the risk of each family member for a sum of Rs.5 Lakh. Validity of the policy was from 31.05.2014 to 30.05.2015 for which premium of Rs. 24,221/- was paid.

4. It was stated by the Complainant that from the MRI Scan dated 31.07.2014 of insured-Sudhir Aggarwal, he came to know that his father was suffering from Cancer problem. Thereafter, for treatment his father was admitted in Rajiv Gandhi Cancer Institute and Research Centre on 03.08.2014 and discharged from there on 18.08.2014. He had spent Rs.5,79,533/- on the said treatment and medical bills, receipts and other relevant record in this regard were submitted with the OPs. Thereafter, under follow up Chemotherapy of his father was done, upon which he had also spent an amount of Rs.5,00,000/-. The Complainant had submitted the claim for reimbursement of medical expenses of Rs.5,79,533/- but the same was rejected by the OPs vide letter dated 26.02.2015 on the ground that the insured was suffering from Haemituria since 3-4 months, DM since 6 months. It was also mentioned that the patient was alcoholic since young age, whereas the Complainant had concealed all these information in the proposal form. Said disease was pre-existing, therefore, the claim was not payable under Clause 4(A) of the Insurance Policy. Thereafter, another amount of Rs.5,39,936/- has been spent on the treatment of his father, which was not reimbursed by the OPs also. Lastly, the father of the Complainant died on 26.03.2016. The Complainant had earlier approached the Insurance Ombudsman, Chandigarh and Permanent Lok Adalat, Kapurthala for the redressal of his grievance but both the Authorities suggested him to file the Complaint before the appropriate Forum, hence, the Complainant approached the District Commission for the redressal of his grievance.

5. Stating the act of the opposite parties to be a case of ‘deficiency in service’ and ‘unfair trade practice’, it was prayed in the Com