PER: HON’BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT

JUDGMENT

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

“....2. Briefly stated the facts of the case are that the complainant had taken an online health insurance policy bearing no. 06-22-1101-8441-00000620 on 17.07.2021 from OP, valid from 17.07.2021 to 16.07.2022 for the sum insured of Rs.3,00,000/- (Rupees Three Lakh).

3. It is further alleged that the complainant got admitted in the Mahavir Multispeciality hospital for treatment on 08.07.2022 and remained hospitalized till 14.07.2022. The hospital generated final bills of Rs.68,902/-(Rupees Sixty Eight Thousand Nine Hundred Two) and the same was paid.

4. The complainant claimed the aforesaid bill amount from the OP vide Claim No. 0C-23-1501-8441-00000161 but the same was rejected by OP vide letter dated 26.08.2022 stating as under:

"Verification of claim documents revealed that claimant was hospitalization and treatment of Urinary Tract Infection. As per verification of claim by our field investigator we have notice non cooperation from hospital as hospital authority did not provide ICP and other treatment records of patient and visited hospital multiple time but all the time we noted non corporation from hospital side. Both treating doctor and pathologist were not available in the hospital at the time of visit and hospital did not provide contact details of both treating doctor and pathologist. We regret to inform you that the claim stands repudiated. Disclosure to information norm: The policy shall be void and all premiums paid thereon shall be forfeited to the company in the event of misrepresentation, mis-description or non-disclosure of any material fact by the policyholder."

5. Hence, this present complaint, it is also alleged that the present case has been being filed within the period of limitation, the cause of when the claim of the complainant was rejected by opposite party vide letter dated 26.08.2022. It is further alleged that the residence of the complainant is situated at "Kakrola" New Delhi. Hence, this court has jurisdiction to entertain the present complaint.

6. It is prayed that OP be directed to pay a sum of Rs.68,902/- (Rupees Sixty Eight Thousand Nine Hundred Two) to complainant with pendent elite and future interest @ 18% p.a. p.a. with effect from the date of repudiation of claim 26.08.2022 till its realization. Opposite party be also directed to verify and produce the medical treatment record and bills of complainant. OP be also directed to pay litigation charges.”

2. The District Commission after taking into consideration the material available on record passed the order dated 01.05.2023, whereby it held as under:

“7. Notice of the complaint was issued to OP, pursuant to which OP entered appearance and filed written statement contesting the complaint on various grounds inter alia that all averments/allegations/assertions/submissions made by the complainant are denied unless having been specifically admitted.

8. It was alleged the complainant has not filed all the relevant records and in the absence of the same, it is very difficult for the respondent to effectively address the issues raised by the complainant.

9. It was also alleged there was no "deficiency of service" on the part of the respondent and the complainant has not come to this Commission with clean hands and she has concealed material facts. It was further alleged that Mahavir Multispecialty hospital refused to co-operate and failed to provide treatment records of the Patient/complainant. The Doctor and the Pathologist were not available at the Hospital. The Hospital authorities also refused to show any bill or receipts to the field investigator of OP. As such the claim of the complainant was repudiated vide letter dated 14.09.2022 being fraudulent and misrepresentation of facts.

10. It was submitted that an insurance policy is a legal contract and its formation is subject to fulfillment of the requisite o