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 a on line health insurance policy bearing no. OG-22-1101-8441-00001362 dated 28.10.2021 from OP. The said policy was valid from 28.10.2021 to 27.10.2022 for the sum insured of Rs.3,00,000/- (Rupees Three Lakh Only).

3. Complainant was hospitalized in the Mahavir Multispeciality Hospital with effect from 18.09.2022 till 28.09.2022. The said hospital generated the final bills of Rs.2.09,453/- (Rupees Two Lakh Nine Thousand Four Hundred Fifty Three) which was paid by complainant. Complainant thereafter claimed the aforesaid bill amount from the opposite party, but OP rejected the Claim No.OC-23-1002-8441-00013034 vide letter dated 14.11.2022 with the reasons mentioned as under:-

"Verification of claim documents reveal aforesaid claimant was hospitalized for Enteric Fever with Sepsis and is claiming for expenses incurred of INR. 2,09,453/- We have received a certificate from treating doctor stating that, patient was not treated by him. Hence, we regret to inform that your claim stands repudiated as a fraudulent, claim in view of misrepresentation of facts. 8. Fraud-i If any claim made by the insured benefits, is in any respect fraudulent or in any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the Insured beneficiary or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the premium paid shall be forfeited. ii. Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all recipient (s) policy holder (s) who has made that particular claim, who shall be jointly and severally liable for such repayment to the insurer ill. For the purpose of this clause, the expression fraud means any of the following acts committed by the insured beneficiary or by his agent or the hospital doctor/any other party acting on behalf of the Insured beneficiary, with intent to deceive the insure or to induce the insurer to issue a insurance policy"

4. It was alleged that complainant having no option to approached this Commission, hence, the present complaint. It is alleged that the complaint has been filed within the period of limitation. The cause of action arose when the claim of the complainant was rejected by opposite party.

5. It is prayed that:

1. OP be directed to pay a sum of Rs.2,09,453/- (Rupees Two Lakh Nine Thousand Four Hundred Fifty Three) with pendent elite interest @ 18% per annum since 14.11.2022 till realization.

2 OP be also directed to verify and produce the medical treatment record and bills of complainant of treatment of complainant from 18.09.2022 to 28.09.2022.

3. The opposite party be also directed to pay the litigation charges.”

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:

“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 of the Mahavir Hospital, the treating doctor of the complainant is Mr. Prag Kalra. However, the said doctor has in Letter stated that he has not treated the complainant, nor has he written the notes of the complainant's hospitalization. The complainant's claim is completely fraudulent.

7. It was admitted that OP had issued a 'Star Package Insurance Policy vide Policy No. OG-22-1101-8441-00001362 to the complainant valid with effect from 28.10.2021 to 27.10.2022 for the sum insured of Rs.3,00,000/- (Rupees Three Lakh) for Health Guard on floater basis.

8. It was also alleged that on receipt of the intimation about the above-said hospitalisation, OP registered a claim