STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.

Date of institution : 29.05.2023 Reserved On : 04.09.2024 Date of decision : 17.02.2025 Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited), Office Address: 5^th Floor, 19 Chawla House, Nehru Palace, New Delhi-110019, through its Chief Executive Officer/Managing Director.

Filing From: Regd. Office Vipul Tech Square Tower-C, 3^rd Floor, Golf Course Road, Sector-43, Gurugram-122009 (Haryana) through its Authorized Signatory.

….Appellant/OP Versus Kanwal Nater Nagrath, aged about 74 years, son of Anant Ram Nagrath, resident of Balaji Nursing Home, Ward No.13, Water Works Road, Mansa.

….Respondent/Complainant First Appeal under Section 41 of the Consumer Protection Act, 2019 against the order dated 27.03.2023 passed by the District Consumer Disputes Redressal Commission, Mansa.

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. Raj K. Narang, Advocate For the Respondent : Sh. Kulwinder Singh, Advocate.

JUSTICE DAYA CHAUDHARY, PRESIDENT Appellant/OP i.e. Care Health Insurance Limited through its Chief Executive Officer/Managing Director has filed the present Appeal under Section 41 of the Consumer Protection Act, 2019 being aggrieved by the order dated 27.03.2023 passed by the District Consumer Disputes Redressal Commission, Mansa (in short, “the District Commission”).

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

3. Briefly, the facts of the case as made out by the Respondent/Complainant in the Complaint filed by him before the District Commission are that he had purchased one Health Insurance Policy from the OP i.e. ‘Group Care (PNB)’ bearing Group Policy No.11561922/COI, which was valid for the period w.e.f. 29.09.2020 to 28.09.2021. The Complainant had paid the premium for the said policy from his Saving Bank Account. During the currency of the said policy, he fell ill on 13.04.2021 due to COVID-19 and remained admitted in Amar Hospital, Patiala and thereafter he was discharged on 18.04.2021. During the course of his treatment, he requested for cashless assistance but it was denied. Thereafter, the Complainant ₹

had raised the claim for an amount of 89,124/- for reimbursement of the medical expenses incurred on his treatment. However, the claim was repudiated by the OP vide letter dated 10.05.2021. The Complaint was filed with the prayer that the directions be issued to the OP to pay ₹

the insurance claim of 89,124/- and also to pay compensation of ₹

30,000/- for causing mental agony and harassment and litigation expenses.

4. Upon issuance of notice in the said Complaint, the OP had appeared before the District Commission through Counsel and filed the written reply, wherein certain preliminary objections were raised. All other averments made in the Complaint were denied. It was prayed that the Complaint be dismissed.

5. The arguments were heard by the Bench of the District Commission consisting of President namely Mr. R.L. Mittal and 2 Members namely Mr. Suraj Goyal and Ms. Sharda Attri.

6. The Complaint was dismissed by Mr. R.L. Mittal, President of the District Commission vide order dated 27.03.2023 However, it was partly allowed by two Members of the District Commission namely Mr. Suraj Goyal and Ms. Sharda Attri vide dissenting order dated 27.03.2023

7. The relevant part of said order dated 27.03.2023 passed by the President of the District Commission as mentioned at Page-21 of the Paperbook is reproduced as under:

“Therefore it stands proved that the insured was suffering with CAD prior to the taking of the disputed insurance policy and he even having knowledge about it, didn’