PER :HON’BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT

JUDGMENT

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

“1. The present complaint has been filed under Section 35 r/w Section 36 of the Consumer Protection Act, 2019 (in short CP Act) and Rule 7 of the Consumer Protection (Consumer Commission Procedure) Regulation, 2020 against Opposite Party (in short OP) alleging deficiency of services.

2. Briefly stated the facts of the case are that opposite party is private limited company registered under the companies Act, 1956.

3. The agents of OP had approached the complainant and offered very lucrative offers and promises and offered to provide health insurance under the name and title of "Young Star Insurance Policy",

4. Complainant being induced by the representation and promises made by OP, accepted the offer and availed a health insurance policy upon the payment of yearly premium. The opposite party issued a Yong Star Insurance policy vide policy no. P/160000/01/2024/002080 dated 29.05.2023 in the name of the complainant for sum insured of Rs.5,00,000/- (Rupees Five Lakh) for a period 29.05.2023 to 28.05.2024.

5. It is further alleged that on 19.07.2023 the complainant developed with some health issues and was diagnosed by the concerned hospital doctors with Plasmodium Falciparum Fever infection and on the directions of the doctors, the complainant was hospitalized on 19.07.2023 in the Anand Hospital, B-13, Nirmal Vihar (Nangloi Road), Najafaghar, New Delhi-110043

It is also alleged that as per the said terms and condition of the policy the complainant approached the opposite party and requested for pre-hospitalization charges of the hospital but the OP illegally simply ignored the request and told the complainant to apply for reimbursement of the claim after the discharge from the hospital. Complainant was forced to pay all the charges of the hospital complainant paid a total of Rs.2,36,628/- (Rupees Two Lakh Thirty Six Thousand Six Hundred Twenty Eight) to the hospital and thereafter applied for reimbursement of the claim with OP and supplied all the documents in respect of the said claim. Opposite party reimbursed part of claim and sent a letter dated 03.09.2023 repudiating the remaining claim stating as under:

"It is observed from the submitted records that the insured patient was admitted and treated in an Excluded Provider (Hospital)."

7. It is also alleged that OP repudiated the claim in mechanical manner. It is further alleged complainant sent a demand notice. It is alleged that cause of action is continuing.

8. It is prayed that:

1. OP be directed to pay a sum of Rs.2,36,628/- (Rupees Two Lakh thirty Six Thousand Six Hundred Twenty Eight) to the complainant-with-interest @18 % p.a. from the date of repudiation of claim i.e. 03.09.2023 til realization.

2. Op be also directed to pay a sum of Rs.3,00,000/- (Rupees Three Lakh) to the complainant as damages/compensation for the loss, pain and injury suffered by the complainant on account of mental agony, harassment and inconvenience due to deficiency in service of opposite party.

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

9. Notice of the complaint was issued to OP, upon which OP entered appearance however as written statement was not filed within the statutory period, the defence of OP was stand struck off vide order dated 02.04.2024.”

2. The District Commission after taking into consideration the material available on record passed the order dated 03.10.2024, whereby it held as under:

“10. In view of the unrebutted testimony of complainant and the documents relied upon, we are of the view that complainant has succeeded in proving that OP was guilty of deficiency of services. We accordingly hold OP/Star Health and Allied Insurance Company Limited guilty of deficiency of services and directed OP to pay Rs. 2,36,628/- (Rupees Two Lakh Thirty Six Thousand Six Hundr