ADDITIONAL BENCH STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH Date of Institution : 26.12.2022 Date of Reserve : 11.03.2026 Date of Decision : 01.04.2026

1. National Insurance Company Limited, through its Branch Manager, Branch Office at 20, Batala Road, Near Gagan Cinema, Amritsar.

2. Park Mediclaim TPA Pvt. Ltd., through its Manager/Officer Incharge, Branch Office, Ludhiana, 2^nd Floor, B-15/17/1, Sona Complex, Room No.11, G.T. Road, Millerganj, Ludhaina-141003.

Now both through their authorized signatory B.K. Angurala Dy.Manager, Regional Office, SCO No.332-334, Sector 34-A, Chandigarh.

…..Appellants/opposite parties Versus Saroj Mahajan aged about 64 years wife of Sh.Madan Mahajan, C/o M/s Geesons Offset Press, Shiv Nagar, Batala Road, Amritsar.

….Respondent/complainant First Appeal under Section 41 of the Consumer Protection Act, 2019 against the order dated 12.09.2022 of the District Consumer Disputes Redressal Commission, Amritsar.

Quorum:-

Mr.Harinderpal Singh Mahal, Presiding Judicial Member Mrs. Kiran Sibal, Member Present:-

For the appellants : Sh.J.P.Nahar, Advocate For the respondent : Sh.Sukhandeep Singh, Advocate HARINDERPAL SINGH MAHAL, PRESIDING JUDICIAL MEMBER This appeal has been preferred by the appellants/opposite parties– National Insurance Company Ltd. & Anr. against the order dated 12.09.2022 passed by District Consumer Disputes Redressal Commission, Amritsar, whereby the complaint filed by the complainant under Section 12 of the Consumer Protection Act (in short ‘the Act’) was allowed with costs and opposite parties were directed to pay the remaining amount of Rs.66,526/- along with interest @9% per annum from the date of filing the complaint till its realization. They were further directed to pay Rs.5,000/- as compensation and Rs.3,000/- as litigation expenses.

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

2. Briefly stated facts of the complaint are that the complainant obtained a Mediclaim Policy bearing No.404402/50/19/10000412 for a period of one year from 22.06.2019 to 21.06.2020 from opposite party by paying the premium of Rs.21,908/-. The risk of the complainant was covered upto Rs.7,50,000/-. During the period of the policy, the complainant was diagnosed with right paraovarian cyst and she was under the treatment of Dr. Seema Sharma of Apollo Hospital, Amritsar and she was admitted to Apollo Hospital, Amritsar on 29.06.2019 and discharged on 01.07.2019. On this, the complainant spent a sum of Rs.1,28,973/- on her treatment. Intimation for hospitalization was given on 29.06.2019, vide email. The complainant submitted all the medical bills and other relevant documents to opposite party No.2 through opposite party No.1 for disbursement of the amount of Rs.1,28,973/- spent by her on her treatment. However, the complainant has received an email dated 15.09.2019 from the opposite parties, vide which the opposite parties have allowed the claim for Rs.48,299/- only and disallowed the remaining amount of Rs.80,674/- on the ground that the patient was billed Rs.1,14,825/- for procedure Lap Open Hysterectomy by Apollo Hospital, whereas the same procedure cost Rs.35,000/- at Fortis Hospital, Amritsar. The opposite parties have no right to withhold the genuine and legitimate claim of complainant on flimsy grounds. It is also submitted that at the time of issuance of the policy, no copy of terms and conditions was ever supplied to the complainant even lateron. Therefore, the said terms and conditions could not become the part of the contract of insurance and they have no legal and binding force between the parties to the contract of insurance. This act and conduct of the opposite party by repudiating the claim of the complainant amounts to deficiency in service, which compelled the complainant to approach the District Commission seeking following reliefs:

i) to pay the claim of Rs.80,674/- along with interest @18%