M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PLOT NO.76, ARERA HILLS, BHOPAL FIRST APPEAL NO.517 OF 2019 (Arising out of order dated 26.02.2019 passed in Case.No.328/2017 by District Commission, Indore no.2)

STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED, 207, SHALIMAR CORPORTE CENTRE 8B, SOUTH TUKOGANJ, INDORE … APPELLANT.

Versus DR.R.K. GUPTA R/O 3 / 4, CLASSIC PURNIMA PARK, BOMBAY HOSPITAL, INDORE .… RESPONDENT.

BEFORE :

HON’BLE JUSTICE SMT.SUNITA YADAV, PRESIDENT HON’BLE DR. (MRS) MONIKA MALIK, MEMBER COUNSEL FOR PARTIES :

Shri Suryakant Bhujade, learned counsel for the appellant.

Ms.Mona Paliwal, learned counsel for the respondent.

O R D E R (Passed on .06.2025)

The following order of the Commission was delivered by Dr.(Mrs) Monika Malik, Member :

This is an appeal by the opposite party / appellant –

Star Health and Allied Insurance Company Limited (hereinafter referred to as ‘Insurance Company’) directed against the order dated 26.02.2019 passed by the District Consumer Disputes Redressal Commission, Indore no.2 (for short ‘District Commission’) in complaint case no.328/2017, whereby the District Commission has allowed the complaint filed by the complainant /

respondent.

2. Briefly stated, facts of the case are that the complainant / respondent had obtained Family Health Optima Insurance Policy vide policy no. P/201114/2010/004429 from the Insurance Company for a period w.e.f. 14.01.2014 to 13.01.2015. Sum assured under the said policy was Rs.3,00,000/-. It is further submitted that the complainant / respondent fell ill and was therefore, admitted in Indraprastha Apollo Hospital, New Delhi from 01.08.2014 to 04.08.2014. Rs.2,82,368/- was spent in his treatment. The Insurance Company however, paid only Rs.1,50,453/-. The complainant / respondent therefore alleged deficiency in service against the Insurance Company, seeking payment of balance amount alongwith compensation and costs.

3. The Insurance Company resisted the complaint on the ground the ground that there has been violation of terms and conditions of the policy by the complainant / respondent. He had availed the facilities of a room, rent of which was over and above his eligibility as per policy. The hospitalization expenses are also calculated proportionately and therefore the discount given by the hospital was proportionately deducted from the claim amount.

Prayer for dismissal of the complaint was thus made.

4. The District Commission allowed the complaint and directed the Insurance Company to pay Rs.1,09,415/- to the complainant / respondent within a period of two months and interest @ 9% p.a. from the date of repudiation of the claim i.e.14.02.2016, till payment. In addition, compensation of Rs.5,000/- and costs of Rs.3,000/- has also been awarded.

5. Heard. Perused the record.

6. Learned counsel for the Insurance Company argued that the expenses related to hospitalization are considered in proportion to the room rent. This specification is clearly stated in the policy which was issued to the complainant / respondent. It is a settled law that terms of the policy shall govern the contract between the parties, they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of policy and not with reference to the definition given in other law. It is presumed that when the parties have entered into a contract of insurance they cannot rely on definition given in other enactment. Learned counsel thus submitted that the amount was deducted by the Insurance Company as per the terms and conditions of the policy and therefore, the impugned order is liable to be set aside.

7. The complainant / respondent has filed written arguments and has submitted that the District Commission has over looked the fact that the deduction towards room rent has been made in excess. Therefore, the complainant / respondent deserves to be paid Rs.1,14,303/- as claim amount, against the directions given in the impu