KIRAN SIBAL, MEMBER

The instant appeal has been filed by the appellant/opposite party No.1 against the impugned order dated 04.08.2022 passed by District Consumer Disputes Redressal Commission, Barnala camp court at Amritsar (in short, “the District Commission”), whereby the complaint filed by complainant against opposite parties (in short ‘OPs’), under Sections 11& 12 of the Consumer Protection Act 1986, has been allowed while granting the following relief:

“15. From the above discussion, it established that the claim repudiated by the opposite party No.1 vide letter dated 08.09.2017 Ex. OP-1/3 was unreasonable and unjustified and there is clear cut deficiency in service on the part of Opposite party No.1 and opposite party No.1 is directed to pay the amount of Rs.52,330/- to the complainant alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite party No.1 is also directed to pay Rs.10,000/- to the complainant as compensation for mental tension and harassment and Rs.5,500/- as costs and litigation expenses. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order.”

2. It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Commission.

3. Brief facts of the case for disposal of the appeal are that OP No.3, who is an employer of the complainant, obtained Group Health Insurance policy for its employees, vide group health policy No.173763- 0000-00/Membership ID 31702442 issued by OP No.1. An amount of Rs.1200/- was deducted from the salary of the complainant towards the premium of the said insurance policy. The said insurance policy has covered cashless medical hospitalization facility upto a sum of Rs.1,00,000/- for complainant and his family members consisting of Mrs. Preeti, wife and Master Joydeep Singh, son. During the validity period of the said policy, the wife of complainant got admitted in the hospital of OP No.5 on 09.05.2017 and delivered a female child. At the time of admission of his wife in the said hospital, the complainant presented the membership card issued by OP No.1 but the hospital authority refused to provide cashless facilities and insisted to deposit the cash amount with it. The complainant spent a total of Rs.52,330/- on the medical treatment of his wife and thereafter, he submitted all the requisite bills along with other relevant documents to OPs No.1 & 2 for reimbursement of the genuine and legitimate claim, but the OPs failed to settle the same. Alleging deficiency in service on the part of OPs, the complainant filed consumer complaint before the District Commission and sought directions against the OPs to pay claim amount to the tune of Rs.52,330/- along with interest @12% p.a. and further to pay Rs.20,000/- as compensation on account of mental agony and harassment; besides cost of litigation.

4. Notice of the complaint was issued to the OPs, but OPs No.2 to 5 failed to appear to contest the complaint despite service. As such, they were proceeded against exparte by the District Commission.

5. Upon notice, OP No.1 appeared through counsel and filed written reply, wherein it raised certain preliminary objections, which are not required to be reproduced here for the sake of brevity. On merits, OP No.1 stated that the wife of the complainant joined the policy on 04.07.2017, whereas she was admitted in the hospital of OP No.5 on 09.05.2017 for taking the said treatment. Since the said hospitalization falls beyond the purview of the policy coverage, the complainant was not entitled for the expenses incurred on his wife’s ailment. Accordingly, the claim was repudiated vide letter dated 08.09.2017. There was no deficiency in service on the part of OP No.1. After denying the other averments made in the complaint, OP No.1 prayed for dismissal of the complaint.

6. The a