IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution: 12.04.2022 Date of hearing: 17.12.2024. Date of Decision: 24.02.2025.

FIRST APPEAL NO.272/2024 IN THE MATTER OF STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED, THROUGH ITS SENIOR MANAGER, 1^st FLOOR, HIMALAYA HOUSE, 23, KASTURBA GANDHI MARG, CONNAUGHT PLACE, NEW DELHI – 110001 …APPELLANT (THROUGH: MR. ABHISHEK NANDA AND MS. YASHIKA SINGH, ADVOCATES)

VERSUS MANPAL, C-88, VIKAS VIHAR, KAKROLA, NEW DELHI – 110078 …RESPONDENT (THROUGH: MR. SHRIPAL, AR OF RESPONDENT)

CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

HON’BLE MR. J.P. AGARWAL, MEMBER (GENERAL)

PER: HON’BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT JUDGMENT

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

1. The present complaint has been filed under Section 12 of the Consumer Protection Act (in short CP Act) against Opposite Party (in short OP) alleging deficiency of services.

2. Briefly stated the facts of the case are that Complainant had taken an online health insurance policy bearing No. P/160000/01/2021/004723 on 09.11.2020 from opposite party. The said policy was valid from 09.11.2020 to 08.11.2021 and Premium of Health Insurance Policy is Rs.13,900/- (Rupees Thirteen Thousand Nine Hundred) paid by complainant.

3. It is further stated that complainant had high fever, burning sensation in urine, vomiting, abdominal pain, weakness etc. So, complainant got admitted in the Anand Hospital Address. B-13, Nirmal Vihar, (Nangloi Raod), Najafghar, New Delhi-110043 from 27.09.2021 to 01.10.2021.

4. Complainant claimed the aforesaid bill amount from the opposite party, vide claim No. CIR/2022/160000/ 3307086, but the opposite party rejected the claim vide letter dated 24.10.2021. Complainant thereafter sent a letter dated

10.11.2021 to OP, but no response was received from OP.

5. It is prayed that OP be directed to pay a sum of Rs.49,765/-

(Rupees Forty Nine Thousand Seven Hundred Sixty Five) to the complainant from the date of repudiation of claim i.e.

24.10.2021 till payment and cost of litigation.”

2. The District Forum –VI, New Delhi after taking into consideration, the material available on record passed the order dated 22.02.2024 in CC No.81/2022, whereby it held as under:

“17. We have heard the AR of complainant and Ld. Counsel for OP and perused the evidence and material on record as well as their written arguments.

18. It is admitted case that complainant had obtained the policy in question from OP which was valid with effect from 09.11.2020 to 08.11.2021 and complainant was hospitalized during the tenure of coverage of the insurance policy. It is the case of OP the claim of complainant was repudiated for violation of the terms and conditions of the policy.

19. It is to be noted that complainant filed all medical bills, purchase vouchers, laboratory reports issued and attested by the Anand Hospital. The repudiation letter states that the claim was repudiated as insured was admitted and treated in an excluded provider Hospital, which was violation of the terms and conditions of the policy.

20. It is to be noted that OP failed to show that the terms and conditions were served on the complainant. Thus we are of the view OP has not filed any document to show that the terms and conditions of the policy which included the exclusion clause were communicated or served on the insured/complainant.

21. As regard the liability of Insurance Company in case the terms and conditions of the policy were not communicated or served on the insured, it has been held by the Hon'ble Supreme Court in M/s Modern Insulators Ltd. Vs. The Oriental Insurance Company 2000 (2) SCC 734 as under:

"It is the fundamental principle of insurance law that utmost good faith must be observed by the contracting parties and good faith forbids either party from non- disclosure of the lads which the parties known. The insured has a duty to disclose and similarly it is the duty of the insurance company and its ag