IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution: 02.08.2023 Date of Hearing: 20.01.2025 Date of Decision: 24.02.2025 FIRST APPEAL NO. – 376/2023 IN THE MATTER OF BAJAJ ALLIANZ GENERAL INSURANCE CO. LTD., 7^TH FLOOR, DLF TOWER 15, SHIVAJI MARG, NEW DELHI -110001 (Through: Mr. Amit Kumar Maihan, Advocate)

…Appellant VERSUS MRS. RAJNI, W/o MR. JITENDER, RZ-65, NAND VIHAR, KAKROLA, NEW DELHI – 110078.

(Through: Mr. Shripal, Authorised Representative …. Respondent CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

HON’BLE MS. PINKI, MEMBER (JUDICIAL)

Present: Ms. Binny Sethi, counsel for the Appellant appeared through VC.

Mr. Shripal, AR for the Respondent.

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

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

“2….The complainant has taken a online health insurance policy bearing No. 12-8450-0000001786-00 on 19.04.2021 from opposite party. It is futher stated that said policy was valid from 19.04.2021 to 18.04.2022 for the sum insured of Rs.3,00,000/- (Three Lacs only).

3. It is further alleged that the complainant got admitted in the Mahavir Multispeciality Hospital for treatment on 02.04.2022 and remained hospitalized till 07.04.2022. The said hospital generated the final bills of Rs 71,345/- (Rupees seventy one thousand three hundred forty five) which was paid by the complainant .

4. Complainant claimed the aforesaid bill amount before the opposite party but claim of complaint No. 220006435P was rejected by opposite party vide letter dated 15.09.2022 stating as under:

Repudiation remarks: Verification of claim documents reveals aforesaid claimant was hospitalized for investigation and treatment of urinary tract infection and is claiming for expenses incurred of INR 71,344/- (Rupees seventy one thousand three hundred forty five). As per received documents we have noticed certain discrepancies and lapses in your hospitalization, which are as follows:

1. Hospital is not registered from DHS Delhi.

2. Patient is not traceable.

3. Duplicate bills did not shared by the hospital.

Hence, we regret to inform you that the claim stands repudiated in view of misrepresentation of facts with non – cooperation.

5. It is alleged that the respondent thereafter sent a letter by speed post with all required documents on 03.10.2022 to the OP/insurance company. That the complainant had claimed the genuine bill of Rs 71,345/- (Rupees seventy one thousand three hundred forty five) from the OP. The complainant has been left with no option but to approach the court, hence, this present complaint. It is further alleged the present case is being filed within the period of limitation. It is also alleged that the cause of action arose to file present complaint when the claim was rejected by opposite party. The residence of the complainant is situated at "Kakrola" New Delhi. Hence, this Court has jurisdiction to entertain the present complaint.

6. It is prayed that the OP be directed to pay a sum of Rs.71,345/- (Rupees seventy one thousand three hundred forty five) to complainant with pendent elite and future interest @ 18 % p.a. from the date of repudiation of the claim 15 .09.2022 till realization. It is also prayed that OP be directed to verify and produce the medical treatment record and bills of complainant of treatment from 02.04.2022 to

07.04.2022. OP be also directed to pay cost of litigation.”

2. The District Commission after taking into consideration the material available on record passed the order dated 10.05.2023 whereby it held as under:

“In the view of the unrebutted testimony of the complainant, we are of a view that the complainant has succeeded in proving that the OP was guilty of deficiency of services in repudiating the claim of complainant. We accordingly hold OP/Bajaj Allianz General Insurance Company guilty of deficiency of services and direct OP to pay Rs. 71,345/- (Rupees seventy one thousand three hundred forty five) to the compla