Present:-

For the appellant : Ms. Swatantar Kapoor, Adv. (through VC)

For the respondents : Sh. Aman Bahri, Sr. Advocate, assisted by Sh. Shivansh Sood, Advocate

VISHAV KANT GARG, MEMBER :

The Appellant/Opposite Party, has filed the present Appeal under Section 41 of the Consumer Protection Act, 2019 (in short the ‘Act’), being aggrieved by the order dated 23.01.2025 passed by the District Consumer Disputes Redressal Commission, Jalandhar (in short, “the District Commission”), whereby the Complaint filed by the Complainants (Respondents herein) had been partly allowed.

It would be apposite to mention here that hereinafter the parties will be referred, as were arrayed before the District Commission.

Briefly, the facts of the case of the Complainants, which are necessary for the disposal of the present Appeal are that the Complainants had been insured under a Mediclaim Policy issued by the OP. Complainant No.2 had undergone medical treatment at Fortis Hospital, Mohali for Dysmenorrhoea. In the said Hospital, surgery was performed upon her. She had incurred Rs.1,11,608/- on the treatment, Rs.4,800/- as medical charges and Rs.50,000/- for various tests, medicine & incidental charges. The claim was submitted to the OP, which was repudiated on 14.06.2019 on the ground that infertility and its related treatment were not covered under the Policy. Being aggrieved by the action of the OP, the Complainants had filed the Complaint before the District Commission with the following prayer:-

“It is, therefore, respectfully as prayed that the present complaint may kindly be allowed, and the opposite party be directed to pay Rs.1,66,408/- to complainant along with up to date interest and also another amount of Rs.2,00,000/- as damages and compensation for causing harassment to complainants on account of unfair trade practice and deficiency in service.”

Upon the issuance of the notice in the said Complaint, the OP had appeared through Counsel and filed the reply/written version. Certain preliminary objections were raised. It was also mentioned that Infertility and failure of IVF were not covered under the Policy. Treatments related to Sterility, Infertility, Assisted Conception and Pregnancy were not covered under the Policy. It was averred that the Complainants claim was not maintainable as it fell under the ‘Exclusion Clause’, hence, the claim had been rightly repudiated. Other averments made in the Complaint were controverted and dismissal of the Complaint was prayed for.

By considering the averments made in the Complaint and reply thereof as well as the oral arguments raised by the Counsel for the parties and documents available on the record, the District Commission had partly allowed the Complaint. The relevant part of the order dated 23.01.2025 as mentioned in Para-10 is reproduced as under:-

“10. In view of the above detailed discussion, the complaint of the complainant is partly allowed and OP is directed to pay Rs.1,66,408/- to the complainant as per Ex.C-4 to Ex. C-17 produced on record, with interest @ 6% per annum from the date of repudiation of the claim till its realization. Further, OP is directed to pay a compensation of Rs.15,000/- for causing mental tension and harassment to the complainant and Rs.10,000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order…”

Being aggrieved by the order dated 23.01.2025 passed by the District Commission, Appellants/Opposite Parties have filed the present Appeal by raising a number of grounds.

Ms. Swatantar Kapoor, Advocate, learned Counsel for the Appellant has submitted that Dr. Heena-Complainant No.2 was diagnosed as a case of ‘primary infertility’ and had a history of Dysmenorrhea. She had approached the Fortis Hospital for its further management where Laproscopic + Hysteroscopy + Chromopertubation was done. However, as the said disease falls under Exclusion Clauses 4.6 of the Policy i.e. treatment rel