CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

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

Present: Ms. Binny Sethi, Counsel for the appellant

(Enrl.No. D/40/2025, Mobile: 9968017751,

Email: binnysethi87@gmail.com)

Mr. Shripal, Counsel for the respondent

Mobile: 9213147616, (Enrl. No.D/11332/24)

Email:vevsshv@gmail.com

PER :HON’BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT

JUDGMENT

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

“The present complaint has been filed under the Consumer Protection Act (in short CP Act) against Opposite Parties (in short OP) alleging deficiency of services.

2. Briefly stated facts of the case are that the complainant had taken a Health Medical Claim Policy bearing No.OG-1101-8429-00000619 dated 24.06.2019 from OP No. I w.e.f. 24.06.2019 to 23.06.2020 for the sum insured of Rs.3,00,000/- (Three Lacs only).

3. It is further alleged that on 01.04.2000, the Complainant got admitted in OP No.2, hospital due to fever, vomiting, Abdomen pain and on 05.04.2020 the complainant was discharged from OP No. 2. It is also alleged that OP No. 2 generated the medical treatment bill of Rs. 37,193/-(Rupees Thirty Seven Thousand One Hundred Ninety Three only) which was paid by Complainant to OP No. 2. The complainant thereafter claimed the aforesaid bill from OP No.1 but the same was repudiated by OP No. 1 vide letter dated 27.07.2020. It is alleged that the medical documents submitted by the Complainant with OP No. I were issued by the OP No. 2.

4. It was also stated that the present case has been filed within the period of limitation. The complainant is a resident of "Kakrola" New Delhi and OP No. 1 works for gain within the jurisdiction of this Commission, hence this Commission has jurisdiction to try and decide the case.

5. It is prayed that OP No.1 be directed to pay a sum of Rs.37,193/-(Rupees Thirty Seven Thousand One Hundred Ninety Three only) toand with pendent elite and future interest @ 18% p.a. from the date of repudiation 27.07.2020 till its realization. It is also prayed OP No. 2 be directed to verify and produce the medical treatment record and bills of complainant w.e.f. 01.04.2020 to 05.04.2020. OP be also directed to pay cost of litigation.

6. Notice of the complaint was issued to OP No.1 and 2, upon which OP No.-1 entered appearance and filed reply/written statement contesting the complaint on various grounds, inter alia that complaint was not maintainable as it was filed on false and frivolous facts. It was also stated that there was no deficiency in service on part of the OP No.1. It was further stated that the admission of the complainant to the OP No. 2 hospital for fever and weakness for four days was without any basis since the pathologist, Dr. R.S. Kushwaha had written a letter to the OP No. 1 stating that the reports of the complainant were fake and had not been verified by him. Dr. R.S. Kushwaha had further stated that he does not visit the OP No. 2/ hospital. It was further alleged that complainant and the OP No. 2 are hand in glove in trying to deceive the OP No. 1 with the intention of getting insurance money from the OP No. 1 by fabricating documents of a medical claim.

7. It was further stated that the standard medical protocols had not been followed during the alleged hospitalization. The complainant had claimed that she was admitted for five days and yet no tests were done the complainant for notifiable diseases which is the standard medical protocol.

8. It was further alleged that the OP No. 2 has also been refusing to provide records of the Complainant to the OP No.1. The OP No. 2 hospitals did not cooperate with the OP No. 1 and no record of alleged treatment was shown despite requests. It was also alleged the clause D of the terms and conditions of the policy on the basis of which the claim was repudiated is as under:

"Where this Policy requires you to do or not to do something, then the complete satisfaction of that requirement by you or someone