PER: HON’BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT

JUDGMENT

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

“2. Briefly stated the facts of the case are that the complainant had taken a on line health insurance policy bearing no. P/160000/01/2019/004550 dated 02.03.2019 from opposite party. The said policy was valid from 02.03.2019 to 01.03.2020 for the sum insured of Rs.3,00,000/- (Rupees Three Lakh Only).

3. Complainant got admitted in the Parth Hospital for his treatment on 10.04.2019 and remained hospitalized till 16.04.2019. The said hospital generated the final bills of Rs.50,541/- (Rupees Fifty Thousand Five Hundred Forty One) which was paid by complainant.

4. Complainant claimed the aforesaid bill amount from the opposite party, but OP rejected the Claim No. CLI/2020/160000/0052200 vide letter dated 30.05.2019 with the reasons stated as under:-

It is observed from the indoor case records the date of discharge is tampered and also written stereotyped. As per information gathered there is no doctor's available in the hospital. Our medical team is of the opinion that the hospitalization of the insured patient is not warranted.

5. It is also alleged that the complainant filed an application before Insurance Ombudsmen, complainant not satisfied with the order of Insurance Ombudsmen.

6. It is alleged that the complaint is being filed within the period of limitation. It is prayed that:

1. OP be directed to pay a sum of Rs.50,541/- (Rupees Fifty Thousand Five Hundred Forty One) to the complainant on account of expenses incurred in medical expenses during the treatment of the complainant/insured along with pendentelite interest @ 18% p.a. from the date of repudiation 30.05.2019 till the actual realization.

2. OP be also directed to pay a sum of Rs.2,00,000/- (Rupees Two Lakh) to the complainant as damages/compensation for the loss, pain and injury on account of mental agony, harassment and inconvenience suffered by the complainant due to deficiency in service of OP.

3. The opposite party be also directed to pay a sum of Rs.1,00,000/-(Rupees One Lakh) on account of litigation expenses.

7. Notice of the complaint was issued to OP, OP was served on 04.08.2023, however as written statement was not filed within the statutory period, the defence of OP was stuck off vide order dated 17.11.2023

8. Section 38(3)(a) of the Consumer Protection Act, 2019 which relates to the period of limitation to file written statement provides as under:-

"(a) refer a copy of such complaint to be opposite party directing him to give him version of the case within a period of thirty days or such extended period not exceeding fifteen days as may be granted by the District Commission

In this regard the Hon'ble Supreme Court has held in the case titled New India Assurance Company Ltd. Vs. Hilli Multipurpose Cold storage Pvt. Ltd. reported in 2020 (5) SCC 757 as under:

"Sub Section (2)(a) of Section 13 of the Consumer Protection Act provides for the opposite party to give his response 'within a period of 30 days or such extended period not exceeding 15 days as may be granted by the District Forum'. The intention of the legislature seems to be very clear that the opposite party would get the time of 30 days, and in addition another 15 days at the discretion under the Act".

10. Complainant filed his evidence by affidavit reiterating therein the averments made in the complaint. Complainant has filed/relied upon policy, the treatment record, the bills issued by Parth Hospital and the repudiation letter.

2. The District Commission after taking into consideration the material available on record passed the judgment dated 25.01.2024, whereby it held as under:

“11. We have heard the AR of complainant and counsel for OP and perused the record.

12. In view of the unrebutted testimony of complainant and the documents relied upon by complainant, we are of the view that complainant has succeeded in proving that OP was guilty of deficiency