IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution: 28.10.2015 Date of Hearing: 27.02.2025 Date of Decision: 17.03.2025 FIRST APPEAL NO-589/2015 IN THE MATTER OF MRS. SHANTA JAIN, WIFE OF MR. D.C. JAIN, RESIDENT OF 42, GROUND FLOOR, SFS DDA FLATS, GULMOHAR ENCLAVE, NEW DELHI-110049 …APPELLANT (Through: Mr. Rakesh Kumar &

Mr. Nitin Kumar, Advocates, Mob.9910280608, 9958471240 Email: rksharma54@gmail.com)

VERSUS

1. NATIONAL INSURANCE COMPANY, DIVISIONAL OFFICE-1, 2E/9, II FLOOR, JHANDEWALAN, NEW DELHI-110055

2. THE NATIONAL INSURANCE COMPANY REGISTERED OFFICE AT:-

3, MIDDLETON STREET, POST BOX NO.9229, KOLKATA-700071 ….RESPONDENTS (Through: Mr. Shimpy Arman Sharma and Ms. Geeta Malhotra, Advocates Mob.9971550603, 9810766150 &

Email: advgeetamalhotra@gmail.com)

CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

HON’BLE MS. PINKI, MEMBER (JUDICIAL)

Present: Mr. Rakesh Kumar and Mr. Aman Kumar Singh, counsel for the appellant.

Ms. Geeta Malhotra, counsel for the respondent.

PER : HON’BLE PINKI, MEMBER (JUDICIAL)

JUDGMENT

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

“The complainant is a mediclaim policy holder of OP no.1. It is alleged by the complainant that she has been availing the medi claim policy since 2001. It is further alleged by the complainant that in the year 2014 she had enhanced the sum insured under the policy upto Rs.5 lakh and had purchased the mediclaim policy vide policy No.350100/48/13/8500000859 for the period from 31.3.2014 to 30.03.2015 for a sum insured of Rs.5,00,000/-

It is further alleged by the complainant that she was admitted in Max Super speciality Hospital on 10.6.2014 as she had to undergo knee replacement and after operation she was discharged on 17.6.2014. It is alleged by the complainant that at the time of discharge the said hospital had raised a bill of Rs.4,36,018.25 and when she lodged a claim with OP for reimbursement of the same. It has paid only a sum of Rs.2,00,000/- despite the fact that insurance policy covered the claim upto Rs.5,00,000/-. It is further alleged by the complainant that she had made several requests to the OP to pay the entire claim amount but no need was paid to her request and she was forced to bear the medical expenses of Rs.2,86,018/- from her own pocket.

The complainant alleged that at the time of issuing the policy, the OP had assured her that company will pay the medical expenses upto 5,00,000/- but the OP had failed to do so which act of OP amounts to deficiency in service and hence the complaint.”

2. The District Commission after taking into consideration the material available on record passed the judgment dated

15.09.2015, whereby it held as follows:

“The counsel for the complainant had contended that the OP had not paid the genuine claim of the complainant on false and flimsy grounds. The counsel for the complainant has forcefully contended that the OP company had received the premium of Insurance policy for a sum insured of Rs.5 lakh and as such they are liable to reimburse the claim of the complainant upto Rs.5 lakh.

The counsel for the OP on the other hand has drawn our attention towards clause no.5.12 of the Mediclaim insurance policy terms and conditions which reads as under:-

5.12 Sum Insured under this policy can be enhanced only at the time of renewal up to next higher slab if Sum Insured under expiring policy is up to Rs.1,00,000 and next two higher slabs if Sum Insured under expiring policy is above Rs.1,00,000/- subject to satisfactory medical check up with regard to health of the insured person and acceptance of additional premium for the enhanced sum Insured. However, continuing or recurrent nature of disease/ complaints which the insured has ever suffered will be excluded from the scope of cover so far as enhancement of Sum Insured is considered.

He has also pointed out to us the relevant contents of discharge summary which reads as under:-

“Mrs. Shanta Jain, 61 year old female presented with complaint