IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution: 18.06.2024 Date of Hearing: 11.11.2025 Date of Decision: 02.12.2025 FIRST APPEAL NO. 429/2024 IN THE MATTER OF MR. NARESH KUMAR, R/O 29 AN BLOCK, GOPAL NAGAR, NAJAFGARH, NEW DELHI-110043.

(Through: Mr. Shripal, Advocate)

Appellant VERSUS ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED, B-1, PLOT NO. 4-2, 3^RD FLOOR, AGARWAL PLAZA BLOCK, JANAKPURI, NEW DEELHI-110058.

(Through: Mr. Praveen Kumar Shahi, Advocate)

…Respondent CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

HON’BLE MS. BIMLA KUMARI, MEMBER (FEMALE)

Present: Mr. Shripal, Counsel for the Appellant, E-mail: vevssshv@gmail.com.

Mr. Praveen Kumar Shahi, Counsel for the Respondent, E-mail:

praveen.shahiadvocate@gmail.com.

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 complainant has filed the complaint under section 12 of Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations that Ombudsman has not given attention to the main facts of the case. The claim is related to the main claim. The earlier claims, which were not related to the main claims, were passed. The policy clearly shows that expenditure on the medicines consumed 30 days before the admission and 60 days after the discharge from the hospital will be reimbursed along with fees of the doctor. There is no word “main claim” in the insurance policy. The OP has deliberately transferred the amount of Rs.5000/- qua claim by NEFT in Axis Bank where he has already closed the account. He has demanded the papers from the Ombudsman from the rejection of the claim but papers were not supplied. The claim of Rs.56373/- + Rs.5000/- was rejected against the terms of the policy. Hence, this complaint.

2. The OP has filed the WS with the averments that complainant has taken health insurance policy which covers his wife and son. The policy was valid from 14.06.2017-13.06.2018. Sh. Sachin Kumar, Son of the complainant, was admitted for renal calculus at Orthoplus Hospital on 20.03.2018 and discharged on 25.03.2018. The cashless claim of Rs.18306/- was settled along with claim of Rs.5000/- for daily hospital allowances. The said amount of Rs.5000/- was transferred by NEFT on 18.04.2018. The complainant was approached the OP for post-settlement of cashless claim of Rs.56,373/- for reimbursement. The scrutiny of pre and post hospitalization documents shows that the claim was not related to the main hospitalization of the complainant. The insured was not admitted. He was taking OPD treatment and visited Anand Hospital for general consultation towards fever and loose motion. On 05.06.2018, SH. B. S. Singhal, treating doctor stated that he has given OPD treatment for malaria and fever which is not related to kidney stone treatment taken in Orthoplus Hospital. The statements dated 19.06.2018 and 22.06.2018 of Dr. B. S. Singhal annexed with the complaint are after thought as Doctor has changed his version to help the complainant. The OP vide letter dated 19.06.2018 has repudiated the claim as same is not related to the main diagnosis. There is no deficiency of service on the part of OP.

3. The complainant has filed replication wherein he has denied the averments of written statement and reiterated the stand taken in the complaint.

4. The parties were directed to lead the evidence.

5. The complainant has filed his own affidavit in evidence and corroborated the version of complaint and placed reliance on the documents Ex.CW1/1 – 7.

6. The OP has filed the affidavit of Sh. Krashanu Pundir, in evidence and corroborated the version of written statement and placed reliance on the documents RW1/1-1/7.”

2. The District Commission after taking into consideration the material available on record passed the order dated 24.05.2024, whereby it held as under:

“7. We have heard the complainant and Ld. Counsel for the OP and perused the entire material on r