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:

“1. The present complaint has been filed under Section 35 read with 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 the complainant had taken a on line health insurance policy bearing no. OG-22-1101-8441-00001156 on dated 01.10.2021 from OP. The said policy was valid from 01.10.2021 to 30.09.2022 for the sum insured of Rs.5,00,000/- (Rupees Five Lakh Only).

3. Complainant was hospitalized in the New Life Multispeciality Hospital with effect from 21.09.2022 till 24.09.2022. The said hospital generated a final bills of Rs.42,530/- (Rupees Forty Two Thousand Five Hundred Thirty), which was paid by complainant. Complainant thereafter claimed the aforesaid bill amount from the opposite party, but OP rejected the Claim No.OC-23-1002-8441-00012617 vide letter dated 12.12.2022 with the reasons mentioned as under:-

Verification of claim documents reveal aforesaid claimant was hospitalized for investigation and treatment of Acute gastroenteritis with Dehydration and is claiming for expenses incurred of INR.42,530/- we have received a certificate from hospital authority stating that, patient was not admitted in their hospital.

Hence, we regret to inform that your claim stands repudiated as a fraudulent claim in view of misrepresentation of facts. Fraud-1. If any claim made by the Insured beneficiary, is in any respect fraudulent, or if any false statement, of declaration is made or used in support thereof, or if any fraudulent means or devise 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.

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

5. It is prayed that:

1. OP be directed to pay a sum of Rs.42,530/- (Rupees Forty Two Thousand Five Hundred Thirty) to the complainant with interest @ 18% per annum from the date of repudiation of the claim till realization.

2. OP be also directed to verify and produce the medical treatment record and bills of complainant of treatment of complainant with effect from 21.09.2022 to 24.09.2022.

3. The opposite party be further directed to pay the litigation expenses.

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 the complainant has not filed all the relevant records and in the absence of the same, it is very challenging for the answering respondent to effectively address the issues raised by the complainant.

7. It was also alleged that there was no "deficiency of service" on the part of the respondent and while the claim was being investigated, it was revealed by certificate issued by hospital that the complainant was not admitted in their hospital. As such, the claim of the complainant was repudiated on 12.12.2022 for being fraudulent and due to misrepresentation of facts.

8. The claim was repudiated under Part IV, Condition 1 which is as under:

"Fraud: If the Insured or any Family Members (s) or any one acting on his/Family Member (3) behalf shall make or advance any claim which is in any respect fraudulent, or if any false declaration be made or used in support thereof or if any fraudulent means or devices are used or forged and/or fabricated claim supporting document