CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL

(PRESIDENT)

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

Present: Ms. Binny Sethi, Counsel for the Appellant

Mr. Shripal, Counsel for the respondent.

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 complainant had taken a on line health insurance policy bearing no. OG-22-1101-8441-00001818 from opposite party. The said policy was valid from 30/12/2021 to 29/12/2022 for the sum insured of Rs.3,00,000/- (Three Lacs Only).

3. That the complainant got admitted in the Prasad Health Care Multispeciality Hospital & Fertility Centre for treatment on 08/11/2022 and remained hospitalized till 12/11/2022. The said hospital generated the final bills Rs.36,847/- (Rupees Thirty Six Thousand Eight Hundred Forty Seven) which was paid by complainant.

4. Complainant claimed the aforesaid bill amount from OP, but the same was rejected with reason stated as under:-

“Verification of claim documents reveal aforesaid claimant was hospitalized for investigation and treatment of Acute Viral Hepatitis (Jaundice) with Enteric Fever and is claiming for expenses incurred of INR.36,847/- (Rupees Thirty Six Thousand Eight Hundred Forty Seven) we have faced non cooperation from insured for verification of claim. Hence, we regret to inform that your claim stands repudiated in view of misrepresentation of facts.2.Condition Precedent to Admission of Liability. The terms and condition of the policy must be fulfilled by the Insured Person for the Company to make any payment for claim (s) arising under the policy”

5. It is alleged that the complaint has been filled within the period of limitation. The cause of action arose when the claim of the complainant was rejected by OP on dated 17/05/2023.

6. It is prayed that OP be directed to pay a sum of Rs.36,847/- (Rupees Thirty Six Thousand Eight Hundred Forty Seven) to the complainant on account of medical expenses with pendentlite interest @18% per annum from 17/05/2023 till the actual realization. Opposite party be also directed pay a sum of Rs.2,00,000/- (Rupees Two Lakh) as damages/compensation for the loss, pain and injury suffered by the complainant on account of mental agony, harassment and inconvenience suffered by the complainant due to deficiency in service and litigation to expenses of Rs.1,00,000/- (Rupees One Lakh).

7. Notice of the complaint was issued to OP, OP was duly served on 03.06.2023. However as written statement was not filed within the statutory period, the defence of OP was struck off vide order dated 07.08.2023.

8. Complainant filed his evidence by affidavit reiterating therein the averments made in the complaint. Complainant relied upon policy, the treatment record, the bills issued by Prasad Health Care Multispecialty Hospital and Fertility Centre, The repudiation letter.

9. We have heard the AR of complainant and counsel for OP and perused the record”

2. The District Commission after taking into consideration the material available on record passed the order dated 05.01.2024, whereby it held as under:

“10. 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 of services in repudiating the claim of complainant. It is to be noted complainant was hospitalized during the tenure of the coverage of policy in the Panel hospital of OP. We accordingly hold OP/Bajaj Allianz General Insurance Company Limited guilty of deficiency of services and direct OP to pay Rs.36,847/- (Rupees Thirty Six Thousand Eight Hundred Forty Seven) to the complainant with interest @ 9% per annum from date of filing of claim within four weeks of date of receipt of order, failing which OP will be liable to pay interest @ 12% per annum till realization. We also direct OP to pay compensation of Rs.25,000/ (Rupees