Central Delhi


SUROJIT PACHAL - Complainant(s)


S.B.I. G. INS. CO. LTD. - Opp.Party(s)

26 Jul 2023


Complaint Case No. CC/167/2018
( Date of Filing : 27 Aug 2018 )
1. S.B.I. G. INS. CO. LTD.
Dated : 26 Jul 2023
Final Order / Judgement

Before  the District Consumer Dispute Redressal Commission [Central], 5th Floor                                                   ISBT Building, Kashmere Gate, Delhi

                                      Complaint Case No.167 /27.08.2018


Surojit Pachal s/o Late Bhim Chandra Pachal

R/o H. No. A-78, Chander Vihar, I.P. Extension,

 Gali No. 10,Near Bengali Kali Mandir, Delhi-11009                             ...Complainant




OP1. The General Manager, S.B.I. General Insurance Co. Ltd.,

TRDP House, 3rd Floor, 46 Pusa Road, Metro Pillar No. 129,

Karol Bagh, New Delhi-110005.

Head Office: S.B.I. General Insurance Co. Ltd.,  

Grievance Redressal Officer, 101,201,301,

Natraj Junction of Western Express Highway

& Andheri Kurla Road, Andheri (East), Mumbai-400069.


OP2- Paramount Health Services TPA Pvt. Ltd.

PlotNo.A-442, Road No.28, MIDC IndustrialArea,

Wagale Estate, Ram Nagar, Vithal Rukmani Mandir,

Thane (West), Maharashtra 400604                                                         ....Opposite Party


                                                                                    Date of filing              27.08.2018

                                                                                    Date of Order:            26.07.2023

Coram: Shri Inder Jeet Singh, President

                Ms. Shahina, Member -Female

                 Shri Vyas Muni Rai,    Member


Inder Jeet Singh, President



1.1. (Introduction to case of parties) - The complaint is filed by insured/complainant against insurer/OP1 and its TPA/OP2 alleging deficiency of services for want of extending cashless facility and later-on declining reimbursement of medical bills claims under the medi-claim policy no.0000000007101472 (being subject matter of this complaint) in respect of hospitalisation and treatment of his wife Smt. Monimala Pachal. In the complaint, the complainant seeks reimbursement of medical bills of Rs.5,66,005 along-with interest of 18%pa, apart from litigation costs of Rs.25,000/-, compensation of Rs.3,00,000/- and other appropriate relief under the circumstances,

           It is relevant to mention that the details of bills is not mentioned in   chronologically way in the body of complaint but otherwise, however,  an attempt is being made in this Final order to put them in chronology that too at one place as matrix of case of complainant so as to keep brevity and clarity. Further, on the same set of facts and figures, the calculation of  balance amount of bills comes to Rs.4,66,005/- and not Rs,5,66,005/- as mentioned in the complaint. Thirdly, there is another policy taken in joint names of Mrs Monimala Pachal (wife of complainant) and Akshay Dave (son in law) from Oriental Insurance Co., its TPA is Vipul Medicorp Insurance TPA Private Ltd.  The complainant has filed record pertaining to it but complainant does not decipher complete details except that it has also extended partly pre-authorisation and sanction for hospitalization expenses of Ms. Monimala Pachal.

            The subject matter of adjudication will be in respect of subject medi-claim policy no.0000000007101472 between the complainant and OP1, for that OP2 is TPA of OP1.

1.2. The OP1 opposes the complainant by denying allegations of deficiency of services,  since parties are governed and bound by terms and conditions of subject policy.  The complainant has concealed pre-existing disease of his wife from the proposal from, which is against the basic principles of utmost good faith under the insurance policy contract. The pre-authorisation/cash-less facility and repudiation  of claim was under the terms and condition of policy, it cannot be construed deficiency of services and complainant is not entitled for any claim/relief.

             It is material to mention, that reply is not strictly as per rules of pleading as each paragraph is not replied specifically but all paragraphs of complainant are replied in one paragraph by grouping as reply to paragraphs 1-15 together. At some places there is use of   'second person ‘You’ for complainant)' , which may be because of cut and paste. But for own convenience, the OP1 devised the way to narrate its case, then preliminary objection, preliminary submission and then consolidated reply on merits in one paragraph.   The reply also mentions that documents are enclosed as Annexure but no document was not annexed.

1.3. OP2 was served with notice on complaint, however, it abstained from the proceedings, thus it was proceeded ex-parte on 03.01.2019.

2.1. (Case of complainant) - The complainant/Insured took a Medi-claim Policy No.0000000007101472 on 12.07.2017 for four years
from OP1/S.B.I. General Insurance Co. Ltd. Delhi Branch, in his name and in name of his wife Smt. Monimala Pachal. It is top policy of Rs. 10,00,000/- and general policy of Rs. 3,00,000/-, which makes complainant’s wife entitled for claim of Rs. 13,00,000/-. The policy was taken on payment of premium of Rs. 19,019/- through cheque.

2.2. Complainant’s wife Smt. Monimala Pachal and son-in-law took another policy in their joint names, from Vipul Med-Corp Insurance TPA Ltd. Gurugaon, Haryana (it needs to refer para 1.1 above that actually the name of other Insurer is Oriental Insurance Co. and its TPA is Vipul Medicorp Insurance TPA Private Ltd., whom the complainant is referring in the complaint).

2.3.1. Complainant’s wife Smt. Monimala Pachal was sick from 01.01.2018 to 16.03.2018, she was admitted in Shanti Mukand Hospital, Vikas Marg Delhi from 22.01.2018 to 01.02.2018, final bill of Rs.1,21,408/- was raised. The TPA Vipul Med-Corp Insurance Pvt. Ltd was requested and a sum of Rs. 97,126/- was sanctioned and payment was received; the balance amount is Rs. 2,42,282/-. Complainant’s wife was discharged on 01.02.2018 (the discharge summary is at page 25-26 of paper-book).

            The complainant applied to OP1 for reimbursement of amount, however, it was repudiated by letter dated 29.05.2018 on the ground “as per policy terms and conditions, expenses related to chronic renal failure, Hypertension and related complications and Diabetes and related complications are excluded for first year of cover from the date of commencement of policy. This claim for hospitalization falls beyond purview of policy coverage and hence not payable.”

2.3.2. The complainant’s wife was also admitted in Fortis Escort Hospital, Delhi, where she remained indoor patient from 07.02.2018 to 21.02.2018 (vide discharge summary at page 44-45 of the paper-book). The total hospitalization and other expenses were Rs. 4,07,571/-, out of which a sum of Rs. 1,74,400/- was authorized/sanctioned by Vipul Med-Corp Insurance Pvt. Ltd (being TPA of the Oriental Insurance Co.).

 The complainant applied to OP1 for reimbursement of amount, however, it was repudiated by letter dated 29.05.2018 on the same earlier ground “as per policy terms and conditions, expenses related to chronic renal failure, Hypertension and related complications and Diabetes and related complications are excluded for first year of cover from the date of commencement of policy. This claim for hospitalization falls beyond purview of policy coverage and hence not payable.”

2.3.3. The complainant’s wife was further admitted in Shanti Mukund Hospital from 05.03.2018 and she remained there admitted upto 16/17.03.2018 and on 17.03.2018 she died in the hospital. The total hospitalization expenses were Rs. 2,22,598/- apart from expenses on medicine/ pharmacy for Rs.85,954/-. The complainant applied for reimbursement of these medical bills, however, it was repudiated by letter dated 05.06.2018 on identical ground “as per policy terms and conditions, expenses related to chronic renal failure, Hypertension and related complications and Diabetes and related complications are excluded for first year of cover from the date of commencement of policy. This claim for hospitalization falls beyond purview of policy coverage and hence not payable.”

2.3.4. The complainant’s wife died on 17.03.2018 during treatment and hospitalisation, which is within the four years of period of policy. The complainant has lodged the claim with original bills to the OPs but it was not reimbursed. The OPs were also sent death certificate on 14.05.2018, apart from other original bills by speed post. The complainant also sent letters dated 04.06.2018 and 19.06.2018 for the claim lodged, which were responded by the OP, the complainant is not satisfied with the reply of OP. The complainant has also been visiting office of OP personally for settlement of the claim but there is no satisfactory reply or settlement of claim. Finally, legal notice dated 11.07.2018 was sent by registered post, however, its reply is not satisfactory. There were no reasons for the OPs to deny the claim oin respect of Ms. Monimala since other TPA Vipul Med-Corp Insurance Pvt. Ltd. had considered and allowed the claim of complainant.

2.4. As the OPs failed to provide proper services as such OPs are liable to pay compensation of Rs. 3,00,000/- towards mental agony and pain, litigation expenses Rs. 25,000/- apart from other medical bills claim of Rs. 5,66,005/-(sic. Rs. 4,66,005/-)  along with interest.

2.5. The complaint is accompanied with identity proof of complainant, copy of health card of insurance cover, bills issued by Shanti Mukund Hospital, authorization letter by Vipul Med-Corp Insurance Pvt. Ltd., discharge summary dated 01.02.2018, medical bills issued by Fortis Escort with payment detail, discharge summary dated 21.02.2018, medicine/ pharmacy bills, death certificate, requests for consideration of medical bills, repudiation letter dated 29.05.2018, another repudiation letter dated 29.05.2018, third repudiation letter dated 05.06.2018, request letters dated 04.06.2018 & 19.06.2018 and copy of legal notice dated 10.07.2018 with postal tickets and its reply dated 30.07.2018.

3.1 (Case of OP1)-  The OP1 opposed the complaint that neither there is any deficiency on the part of OP1 nor violation of terms and conditions of policy to make the complainant entitled for any relief. The complainant has approached the Consumer Forum/ Commission without clean hands, he is guilty of concealing the material facts. The complaint deserves dismissal.

3.2. The OP1 opposed the Complaint that the complainant is not entitled  for any relief in equity, since he approached this Hon'ble Forum without clean hands by concealing material facts. The documents related to health of complainant's wife clearly depicts that she is a diagnosed case of Diabetes and she was getting treatment for 1 year.  The complainant also admits in complaint about the diseases. Thus, based on said non-disclosure of the material facts at the time of availing the policy, the claim was repudiated by OP1 and on same basis the complaint is liable to be dismissed.  Moreover, it is settled proposition of law that the contract of Insurance is contract of utmost good faith, and every material fact must be disclosed, otherwise, it a valid ground for recession of the contract.

            The ailment of Diabetes was only in the personal knowledge of the Complainant, who had an absolute duty to disclose correctly all material facts.  The repudiation of complainant's claim on the basis of non-disclosure of material facts is valid reason and in consonance with the terms and conditions of the policy, thus complaint is without cause of action, which now renders dismissal of the complaint. The complaint is abuse of process of law,  since there is no deficiency of services nor OP1 indulged in any unfair trade practices.

3.3. A Group Health insurance Policy Bearing No. 0000000007101472 was issued by OP1/SBI General in the name of Complainant w.e.f.12.07.2017 to midnight of 11.07.2018 subject to its terms and conditions and any claim could admissible in adherence to the policy  A reimbursement claim no: 3886389 /HI-101789 under the policy was registered with OP1 on behalf of "Mrs Monimala Pachal",  for her Hospitalisation expenses for the treatment of "chronic kidney disease stage 5 on maintenance of haemodialysis (initiated on 08/02/2018), Type-II Diabetes Mellitus, Hypertension, Bilateral Pleural effusion-uremic, pericardia effusion, uremic, pericardia, effusion, hypothyroidism for which internal jugular vein permacath insertion was done. The insured was hospitalized from 07/02/2018 to 21/02/2018; in "Escorts Heart Institute and Research Centre" for the aforesaid treatment. Then immediately, the OP had assessed all the claim documents and scrutinized all the relevant circumstances to evaluate the authenticity of complainant claim under terms and conditions of the policy.  However, admission of complainant's wife on 7.2.2018 was within one year of the policy that too for specified disease, thus the claim for hospitalization falls beyond purview of policy coverage and it was not payable by the company, as per exclusion clause 3 of the policy, which reads as:

"Exclusions applicable to first year of cover from commencement of the Policy from the following Diseases / Illness and its related complications unless an add on cover waiving this exclusion is purchased by payment of additional premium to Us: (IX) Hypertension. Heart Disease and related complications; (XVIII) Diabetes and related complications: (xviii) Chronic Renal failure; This Exclusion shall apply also to the extent of the amount by which the limit of indemnity has been increased if the Policy is a renewal of the Group Health Insurance Policy with Insurer without break in cover for at least 1 year".


In view of  this assessment the reimbursement  complainant's claim bearing no. 3886389/1-11-101789 was found untenable and it was denied, which was informed  to complainant by letter dated 05.06.2018.

3.4. As per procedure for availing insurance policy, the complainant submitted the proposal form and complainant had signed it and submitted the said form after going through terms and conditions of the policy, at the time of filling up proposal form regarding porting of policy from previous health insurance co. He was also explained all terms and conditions by the insurance agent,  then after cognizance thereof, the policy was taken by the complainant. Moreover, he was also issued insurance policy kit, containing all relevant documents and complainant had opportunity to verify and examine the benefit, terms and conditions of the policy. The complainant never approached to OP1 with regard to any terms or conditions of policy not acceptable or understandable. The complainant is strictly bound by the terms and conditions of policy.

            However, despite knowing the ailments of diabetes etc. the complainant suppressed it from the OP1 at the time of taking subject policy, therefore, claim is not maintainable. In addition, as per the terms and conditions of policy, the claim cannot be allowed because of exclusion clause of treatment in the first year of policy. The complaint is liable to be dismissed.

3.5. The reply is stated to be signed by duly authorized attorney by virtue of power of attorney annexed with the reply, whereas neither power of attorney nor any other document referred in the reply was annexed.

4. (Replication of complainant) – The complainant refutes allegations of reply that nothing was concealed from the OP1 at the time of taking the insurance policy or submitting the proposal form. His wife was not suffering from diabetic for the last one year. The complainant was not provided any terms and conditions of policy except a health card of cover note, which is already appended with the complaint. Moreover, he was also not informed of any terms and conditions through its representative. The complainant was kept in dark by the officials of OP1. In addition, the complainant’s wife was got medically checked up by the OP1 at the time of giving of policy vis-à-vis in case the complainant’s wife was found of any sickness, in such medical examination, then why OP1 issued the policy? The policy was issued considering all record inclusive of medical examination got done by OP1. It is a valid and proper claim lodged. The complaint is correct.

5.1. (Evidence)- Complainant led his exclusive evidence by filing his detailed affidavit, supported with documentary record, which has been annexed with the complaint; in addition some of original bills  medicine  were annexed with the affidavit.

 5.2. On the other side, OP1 led evidence by filing affidavit of Sh. Jitendra Dhabhai, accompanying with copy of special power of attorney, discharge summary and denial of cashless access letter dated 08.02.2018 issued by OP2 (Ex.R1-3).. It is relevant to mention that OP1 had not filed this record with the reply but all of a sudden,  it was filed with the affidavit without permission of Commission, which is against the norms and procedure.

6.1 (Final hearing)- The complainant and OPs were given opportunity to file their written arguments, consequently the complainant and OP1 have filed their respective written arguments. They were also given opportunity to make oral submissions, thus, Sh. R.C. Anand, Advocate for complainant made the oral submission but OP1 failed to make the submission orally.

However, the case of both the side will be considered on merits on the basis of material on record, besides written arguments apart from the oral submissions on behalf of complainant. The submissions of both the sides are based on record, which is in fact replica of their case.

6.2. In addition, the complainant has fortifies its contentions on the basis of following case law:-

(a)  National Insurance Co. Ltd Vs Raj Narain 1 (2008) CPJ 501 NC and  Praveen Damini Vs. OIC (RP No. 1696/2005, dod 03.10.2006, NC), that most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made  liable to suffer because of insurance company relies on their clause 4.1 of the policy in mala-fide manner to repudiate all the claims.


(b) Tarlok Chand Khanna Vs United India Insurance co Ltd RP no.68/2007 dod 16.8.2011 NC - It is settled law that the onus to prove that the insurance had a pre-existing disease was on the respondent, who has stated so.


(c) National Insurance Co. Ltd Vs Umesh Prasad Verma & anr.  FA no.25/79 0.12.2015 - The burden to prove that the insured had taken medical treatment within period of preceding 12. months and he fraudulently suppressed the same, was on the insurer and mere production of opinion of the Doctor, is not sufficient to prove that the insured was having pre-existing disease and he had suppressed material facts. The burden of proof establishing pre existing disease and the insured was having knowledge regarding the disease, is on insurer. The documents filed by the appellants (OPs), are not sufficient to prove the pre-existing disease of the respondent No.1 (complainant No.1). Therefore, merely filing the opinion of Dr. Rajesh M. Ballal and report of Dr.
Avijit Royzada, are not sufficient to prove that the respondent No. 1 (complainant No.1) was having knowledge regarding his pre- existing disease and he malafidely suppressed the above facts from the appellants (OPs) at the time of making proposal for the insurance policy, therefore, the repudiation of the claim of the respondent No. 1 (complainant No.1) by the appellants (OPs) on the ground of not disclosing the material information, is erroneous and thus the appellants (OPs) have committed deficiency in service by repudiating the claim on the ground of suppression.



6.3. Similarly, the OP1 in its pleading as well as in the written arguments fortifies its contentions from following cases:-

(i) Satwant Kaur Sandhu Us.
New India Assurance Company Ltd. (2009) 8 SCC 316 that any fact which would influence the judgment of a prudent insurer in fixing the premium or determining whether he would like to accept the risk or which fact goes to the root of the contract of insurance and has a bearing on the risk involved would be «material fact which the insured is obliged to disclose. Further, when information on specific aspect is asked for in the proposal form, an assured is under solemn obligation make a true and full disclosure of the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not.


(ii) Mrs. Shyni Valsan Pombally Vs State Bank of India (Revision Petition No. 3947 of 2013) it was observed:
"It is a well settled proposition of law that a contract of insurance is based on the principle of utmost good faith - uberrimae fidei, applicable to both the parties. The rule of non-disclosure of material facts vitiating a policy still holds the field. The bargaining position of the parties in a contract of insurance is unequal. The insured knows all the facts, the insurer is unaware of anything which may be material to the risk. Very often, it is the insured who is the sole person who has this knowledge. The insurer may not even have the means to find out facts which would materially affect the risk. The law, therefore, enjoins on the insured an absolute duty to disclose correctly all material facts which are within his personal knowledge or which he ought to have known had he made reasonable inquiries. A contract of insurance, therefore, can be repudiated for non disclosure of "material facts."


(iii) P C Chako & anar Vs Chairman Life Insurance Corporation of India 2007 (13) Scale 329, wherein, it was observed pertaining to the proposal form and held that a deliberate wrong answer which has a great bearing on the contract of insurance, if discovered may lead to the policy being vitiated in Law.”


(iv) Haji Ahmed Yar Khan Vs Abdul Gani Khan AIR 1937 Nag 270 at 272,  it was held that there is no general duty to speak or to disclose facts, which are or might be equally within the means of knowledge of both parties. There are special duties of disclosure in particular classes of contracts, viz. in contracts between an insurer and the insured, and where one party stands in a fiduciary relationship with the other. In such contacts of uberimma fides there is a legal and equitable duty on the parties, not only to state truly whatever is stated, but also to divulge with candor and completeness, facts regarding which there is no objection to disclose.


7.1 (Findings)- The contentions of both the sides are considered keeping in view the material on record. It is apparent that both the sides are referring and relying upon the documentary records, especially the OP1 has much emphasized on the proposal form, its content, regarding declaration of pre-existing disease and other terms and conditions of policy. The following conclusions are drawn:-

(i) The OP1 contends that the proposal form was filled in after understanding the terms and conditions and the same was accepted by the complainant while taking the policy and the complainant is bound by the terms and conditions of such policy. On the other side, complainant counters it that nothing was concealed from the proposal form, the OP1 had also got examined medically complainant’s wife before issuing the insurance policy.

            The complainant has proved health card issued by the OP1 but OP1 has neither filed nor proved the proposal form nor the insurance policy. It establishes that complainant was not provided with terms and conditions of policy nor copy of proposal form.


(ii) The terms and conditions of policy could be complied with when the insured is provided with the terms and conditions of policy along with the policy. The OP1 has given consolidated reply to paragraphs 1 to 15 of complaint together and in single paragraph reply in the written statement, the OP1 does not dispute about issue of health card;  but the health card does not bear/contain terms and conditions of policy. To say, the complainant was not provided with terms and conditions of policy.


(iii) In Manmohan Nanda Vs United-India Assurance Co. [Civil Appeal no. 8386/2013) decided on 6.12.2021 by Hon'ble Supreme Court of India has also dealt the regulations 'the IRDA (Protection of Policyholder' Interests) Regulations 2002' and  it was held (in paragraph 34 thereof) "that just as insured has a duty to disclose all material facts, the insurer must also inform the insured about the terms and conditions of policy that is going to be issued to him and must strictly confirm to the statement in the proposal form or prospectus or those made through its agents. Thus, principle of utmost good faith imposes meaningful reciprocal duties owned by the insured to the insurer and vice-versa".


(iv) Moreover, in Manmohan Nanda Vs United- India Assurance Co. [Civil Appeal no. 8386/2013) decided on 6.12.2021 (paragraph 52, (v) , it was also held ‘the insurance company has the right to seek details regarding medical conditions, if any, of the proposer,  by getting the proposer examined by one of its empanelled doctors. If on the consideration of the medical report, the insurance company is satisfied about the medical condition of the proposer and that there is no risk of pre-existing illness, and on such satisfaction if has issued the policy, it cannot, thereafter, contend that there was a possible pre-existing illness or sickness which has led to the claim being made by the insured and for that reason repudiate the claim.


(v) In  Bharat Watch Company (through its partners) vs National Insurance Co. Ltd., Civil Appeal no. 3912/2019 in SLP(C) no. 25468/2016, it was held that in the absence of appellant being made aware of terms of exclusions, it is not open to the insurer to rely upon exclusionary clauses.


(vi) The complainant has proved pre-authorisation letter (at page no. 20 of paper-book of complainant) by Vipul Med-Corp Insurance TPA Pvt. Ltd. (who is TPA of Oriental Insurance Co. Ltd. in other policy) and as per this pre-authorisation letter for treatment and guarantee period, it mentions that patient Monimalan was  being given treatment chronic renal failure and an amount of Rs. 97,126/- was sanctioned against bill of Rs. 1,21,408/-.

            It is admitted case of OP1 that there was portability of insurance policy from the previous policy, however, the OP1 declined the claim on the basis of non-disclosure of the disease but Vipul Med-Corp Insurance TPA Pvt. Ltd. had pre-authorised the sanction, without any such objection. Had there been concealment of fact of non-disclosure of previous diseases, the said Vipul Med-Corp Insurance TPA Pvt. Ltd. would not have pre-authorised the sanction.  OP2 could also verify the same or if so verified but it has not been proved by OP1.


(vii) The OP1 could not establish that there was concealment of material facts by the complainant or ailment of wife of complainant.


(viii) Neither OP1 provec that there was concealment of ailment in the proposal form, nor that it was discovered in the medical examination of complainant’s wife prior to issuing the policy vis-à-vis the OP was supposed to furnish & prove the medical examination report along with proposal form to fortify its stand taken in the written statement.


(ix) The OP1 could not prove the terms and conditions of the policy were provided to the complainant nor those terms and conditions have been proved in the present complaint. When the terms and conditions have not been supplied to complainant nor proved in the present case, then it is mystery for all as to what are exactly the terms and conditions of the policy.


(x) The OP1 has filed denial of cashless access dated 08.02.2018 (Exh. R1-3), which was not filed with the reply, however, in the said denial, the OP1 took the plea that there was pre-existing ailment, accordingly as per terms and conditions of pre-existing ailment are not payable for first four years of policy period and the cashless benefit was declined. Whereas in the repudiation letters issue from time to time, the OP1 also supplemented that certain other chronic disease are not covered for the first year of cover from the date of commencement of policy. However, again those terms and conditions have not been proved by the OP1.


(xi) What appears from the plea of OP1 that inferences are being drawn from the discharge summary dated 21.02.2018 (which was filed by the OP1 with affidavit of evidence; the complainant had also filed the same with the complaint and also proved the same in evidence), that the complainant’s wife was chronic patient or suffering from ailment which was not disclosed in the proposal form. But it should not be forgotten that there was existence of previous policy in which Vipul Med-Corp Insurance TPA Pvt. Ltd. had sanctioned pre-authorisation considering the ailment & treatment of wife of complainant  vis-à-vis OP1 cannot derive any benefit from the discharge summary by making such inference since the OP1 was required to prove independently pre-existing ailments particularly by establishing proposal form as well as medical examination conducted prior to issuing the policy or other medical record, which OP1 failed.


In view of the aforementioned conclusion, the circumstances established proves the case of complainant that his wife remained under-treatment from time to time at Shanti Mukund Hospital and Fortis Escort Hospital, where she was hospitalized from 22.01.2018 to 05.03.2018 from time to time and medical expenses inclusive on medicine were incurred, the complainant was also paid part payment under the policy issued by Oriental Insurance Co., however, the claim lodged under the subject policy issued by OP1 was declined, it amounts to deficiency in services as valid claim lodged was declined on grounds of concealment of material fact of pre-existing ailment, which could not have been established by OP1. So, the complainant is held entitled for reimbursement of medi-claim amounts of Rs 4,66,005/-, which has been proved through medical papers and bills (there is miscalculation of amount in the complaint of Rs. 5,66,005/- but on calculation the actual amount come to Rs. 4,66,005/-).

7.2. The complainant claims interest of 18 % pa but as such there is no specified rate of interest. Since the complainant has parted with his money, therefore, interest at the rate of 6% pa from the date of complaint till realization of amount in favor of complainant will meet both ends.

7.3. The complainant seeks compensation of Rs. 3,00,000/- (mentioned in the body of complaint and in written argument) on account of mental pain, harassment and agony, cost of Rs. 25,000/- and other appropriate relief. However, the circumstances of ailment, claim for medical expenses and efforts made are speaking themselves that he had faced difficulty, inconvenience and other trauma,  particularly he has been approaching the OP1 as well as writing to the OP1 to pay legitimate medical bills amount, therefore, compensation of Rs. 30,000/- is allowed in his favour and against the OP1. Cost is also quantified as Rs. 10,000/-. No order against OP2

8. Accordingly, the complaint is allowed in favour of complainant and against the OP1 to refund/ reimburse medical bill amount of Rs.4,66,005/- along-with simple interest @ 6%pa from the date of complaint till realization of amount; apart from to pay compensation of Rs.30,000/- & costs of Rs.10,000/- to complainant. 

            OP1 is also directed to return/pay the amount within 30 days from the date of receipt of this order. In case amount is not paid within 30 days from the date of receipt of order, the interest will be 8% per annum on amount of Rs.4,66,005/-. 

9.  Announced on this  26th July 2023 [श्र!वण 4, साका 1945]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.


[Vyas Muni Rai]                                 [ Shahina]                               [Inder Jeet Singh]

           Member                                   Member (Female)                                President


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