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 the complainant had taken a on line health insurance policy bearing No. OG-23-1101-8441-00000078 on 20.04.2022 from opposite party. The said policy was valid from 20.04.2022 to 19.04.2023 for the sum insured of Rs. 10,00,000/- (Rupees Ten Lakh).

3. The son of complainant Subham got admitted in the New Life Multispecialty Hospital for treatment on 17.06.2022 at 10:50 am and remained hospitalized till 01:10 Pm. The said hospital generated the final bills of Rs.40,400/- (Rupees Forty Thousand Four Hundred) which was paid by complainant. The complainant alleged that all documents were sent by Email regarding Claim no. OC-23-1002-8441-00004914 to the opposite party, but no response was received.

4. The complainant having been left with no option approached this Commission, hence, this present complaint.

5. It is prayed that OP be directed to pay a sum of Rs.40,400/- (Rupees Forty Thousand Four Hundred) to complainant with pendentelite and future interest @ 18% p.a. since the date of filing of 23.06.2022.

6. Notice of the complaint was issued to OP, upon which OP entered appearance and filed written statement contesting the case on various grounds inter alia that as per the Discharge Summary and the claim form of the Mahavir Multispecialty Hospital, the patient Subham was treated by Dr. Prag Kalra. Whereas, Dr. Prag Kalra has stated in a Letter that he has not treated Subham and has not written the medical notes. It was alleged that the opposite party has rightly repudiated the claim on the same ground as per Part D-General Condition No. IV (1) and (5) of the poliey wordings.

7. It was alleged that it is a well settled principles of insurance law that the terms and conditions of the policy wordings are strictly binding on the parties. Since the opposite party has repudiated the claim of the complainant in compliance of the terms and conditions of the policy wordings, hence, there is no deficiency in service or unfair trade practice on the part of the opposite party. Hence, the complaint of the complainants is liable to be dismissed with costs.

8. Complainant filed rejoinder reiterating therein the averments made in the complaint and denying all the allegation made in the written statement. Both parties thereafter filed their evidence by way of affidavits.

9. We have heard the AR of complainant and Ld. counsel for OP and perused the evidence and material on record as well as their written arguments.

10. Complainant filed rejoinder reiterating therein the averments made in the complaint, she stated that she had filed the first consultation OPD record. In the rejoinder complainant stated as regard the objection of OP that there was no change in the line of treatment even when fever did not subside, this was the decision of the treating doctor/hospital and not complainant. As regards the objection of OP that higher antibiotics were given without prior OPD treatment it was stated that it was the decision of treating doctor/hospital. It was stated the complainant has filed the Pathology contact details. It was also stated that complainant was hospitalized in emergency and the registration of the hospital was under process. Complainant filed a letter dated 09.08.2022 which shows that the registration of the Hospital was under process. As regards the contention of OP that all indoor case paper were in the same handwriting, it was stated that OP ought to file the report of forensic expert in this regard.”

2. The District Commission after taking into consideration the material available on record passed the order dated 07.02.2024 whereby it held as under:

“11. We have h