Ms. Mandeep Kaur, Member : Order of this Commission will dispose of the present complaint filed by the complainant under section 34 & 35 of the Consumer Protection Act, 2019.
Brief facts and pleadings
1. Brief facts of the case of the complaint are that complainant obtained Mediclaim Health Insurance Plan from the opposite party vide policy no. 73091854 covering insurance period w.e.f. 19-OCT-2024 to 28-OCT-2025 for sum insured of Rs.25,00,000/- and in respect thereof the requisite premium of Rs. 34,229/- was paid by the complainant to the opposite party covering the risk of complainant, his wife Smt. Savneet Kaur and his minor son Mr. Mehtab Singh Bhangu , copy of insurance policy schedule is Ex.C-2. It is important to mention that only schedule of the Insurance policy was supplied to the complainant, but the opposite party never supplied any terms and conditions of the impugned insurance to the complainant muchless the alleged terms and conditions ever formed part of contract between the parties. The complainant is regularly availing Mediclaim insurance from the Insurance Company since 25- OCT-2017 continuously without any break and the premium of every insurance policy has been paid by the complainant to the Insurance Company from time to time. It is further pointed out that prior to that complainant was getting mediclaim insurance from NIVA BUPA HEALTH INSURANCE COMPANY and later on the policy was port on
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the allurements and persuasions made by the representatives of opposite party. It is worthy to mention that at the time of porting impugned Mediclaim insurance policy from the opposite party the concerned agent of opposite party duly assured the complainant that in the event of getting any medical treatment opposite party will indemnify the complainant and on the basis of assurances of opposite party as stated above the Mediclaim policy in question was obtained by the complainant and in respect thereof the regular premium was paid by the complainant without any lapse as detailed above. It is also pointed out that since at the time of obtaining the impugned mediclalm insurance policy all the insured family members of the complainant quite fit and enjoying good health and not suffering from any kind of illness and was not getting any medication before taking the said mediclaim insurance policy. It is pertinent to mention that during the currency of impugned insurance policy as stated above the son of the complainant Master Mehtab Singh Bhangu suffered with HIGH GRADE FEVER ON AND OFF, LOOSE STOOOLS
(MANY EPISODE), VOMITING, POOR ORAL INTAKE AND
DEHYDRATION and approached with the complainant at Apollo Hospital at court Road, Amritsar on 04.06.2025 and after diagnosing the health condition of the son of the complainant in the OPD, the concerned doctor advice the complainant for providing emergent medical treatment to the son of the complainant and advice for the admission of the son of
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the complainant and as such the son of the complainant was admitted in the hospital as per the advice of the treating doctor. The copy of the OPD slip is Ex.C-3. The hospital authorities were informed about the aforesaid health insurance policy of the complainant and the insurance papers were submitted to the opposite party and accordingly, the opposite party was duly informed regarding ailment-and treatment of policy holder Master Mehtab Singh son of the complainant, who remained admitted in the said hospital on 04.06.2025 at 09:22 and was discharged on 06.06.2025 Late night after getting conservative medical treatment and at the time of admission he was diagnosed with Age with Severe Dehydration, copy of entire medical record including all medical tests, investigations, Discharge summary, USG. WHOLE ABDOMEN etc. is Ex.C-4. It is pertinent to mention that it was a cashless insurance policy and the opposite party was under obligation to pay the entire amount towards the medical treatment obtained by the son of complainant and the complainant lodged his claim No. 96209256-00 and the opposite party illegally and unlawfully assigning the reason that "as treatment possible or could be managed on OPD basis and not in daycare list hence the claim is rejected, which is an arbitrary, illegal and unlawful manner, which is not sustainable in the eyes of law especially when the opposite party is legally bound to pay the genuine claim to the complainant. The copy of said Rejection letter dated 23.06.2025 is Ex.C-5. The
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complainant had furnished the copies of all the relevant documents required by the opposite party for the reimbursement the claim of the complainant but the plea raised by the opposite party for repudiating the genuine claim of complainant is absolutely false, frivolous and arbitrary. Not only this, even the complainant had also made various visits to the opposite party thereby satisfying all the requisite queries raised by opposite party, but all in vain. The opposite party has repudiated/denied the genuine and legitimate claim of the complainant on false and flimsy ground as stated above. The opposite party was under legal obligation to pay the claim amount of Rs.31,148/- to the complainant as stated above, but to the utter surprise of the complainant the opposite party did not pay the genuine and legitimate claim to the complainant and the alleged act of opposite party of nonpayment of said amount is illegal, unlawful, without any basis especially when the terms and conditions of policy were not at all supplied by the opposite party to the complainant. The aforesaid act of the opposite party amounts to deficiency in service which has caused has lot of harassment, mental pain and agony to the complainant . Hence, this complaint seeking following reliefs:-
i) Opposite party be directed to pay the claim of Rs. 31148/- alongwith interest @ 12% p.a.
ii) Opposite party may also be directed to award compensation of Rs.1,00,000/- to the complainant for causing mental harassment.
iii) Opposite party be directed to pay Rs.22000/- as litigation expenses to the complainant.
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iv) Any other relief to which the complainant is found entitled be also awarded to the complainant.
2. Upon notice, opposite party appeared and filed written version taking certain preliminary objections that the present consumer complaint filed by the Complainant is false frivolous, vexatious, misconceived, and devoid of any merit either in law or on facts, and is solely intended to extract unlawful enrichment from the answering Opposite Party; that the Opposite Party is specialized health insurance company duly licensed by the IRDAI engaged in offering various health-related insurance products, including Health Insurance, Top-up Coverage, Personal Accident, Critical Illness International Travel Insurance, etc., in accordance with applicable laws and regulatory guidelines; that no cause of action has ever arisen in favour of the Complainant against Opposite Party. The claim under the health insurance policy was rightly repudiated in accordance with the policy terms and conditions accepted by the insured at the time of inception; that the Complainant has failed to discharge the burden of proving deficiency in service, as required under law. The respondent Company had issued a health insurance policy titled Care Supreme,"
bearing Policy No. 73091854, for the period 25-10-2023 to 24-10-2024, to the Complainant for a sum insured of Rs.25,00,000/-covering his Spouse and son i.e. insured subject to terms and conditions of the policy. The policy was renewed for the period of 29-10-2024 to 28-10-2025. That the relevant documents together with Policy. Terms & Conditions,
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Premium Acknowledgement, Key Policy Information and claim process together with policy were shared through email on registered email id:
gurvinder047@gmail.com on 29-10-2024. All the policy documents including terms and conditions were delivered to the insured through link shared by SMS. No grievance or objection was raised within the free-look period. Copy of the Policy Certificate, its terms and conditions and E- POD details are collectively annexed herewith as Annexure-1 (Colly.). A reimbursement claim was received from the complainant for Insured's hospitalization at Apollo Hospitals, Amritsar from 04-06-2022 for the provisional diagnosis of Age with Dehydration and upon careful examination of the claim documents, it was found that:
i That according to the Discharge Summary of the insured, TLC count was in normal limits on the day of admission which usually does not happen in case of infection.
ii. That insured was diagnosed with dehydration and was admitted with the complaints of vomiting but the serum electrolyte level was in normal limits on the day of admission which can be cured on an OPD basis.
iii. That according to the discharge summary of the patient, vitals were not noted at the time of admission.
Copies of the discharge summary & medical documents are Annexure-2 (Colly.). On the basis of the above mentioned observation the respondent
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party rejected the claim vide letter dated 23.6.2025 on the following reasons:-
4.1.(B).1 PERMANENT EXCLUSION: ADMISSION PRIMARILY
FOR INVESTIGATION AND EVALUATION-(CODE EXCL-04)
COULD HAVE BEEN MANAGED ON OPD BASIS.
4.1.(b).1 PERMANENT EXCLUSION ADMISSION PRIMARILY FOR INVESTIGATION AND EVALUATION (Code Excl 04) POLICY TERMS & CONDITIONS:
4. Exclusions:
4.1 Standard Exclusions
(b) Permanent Exclusions:
1. Investigation & Evaluation: (Code-Exc104)
"a. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
Copy of Rejection Letter is annexed as Annexure-3. While submitting that there is no deficiency in service and while denying and controverting other allegations, dismissal of complaint was prayed. Evidence of the parties and Arguments
3. Alongwith the complaint, complainant has filed his affidavit Ex.C- 1, copy of Insu. policy schedule Ex.C-2,, copy of OPD slip Ex.C-3, copy of entire medical record Ex.C-4 (colly), copy of rejection letter Ex.C-5, copy of medical bills Ex.C-6.
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4. On the other hand opposite party alongwith written version has filed copy of policy Annexure I (colly), copies of discharge summary & medical documents Annexure 2 (colly), copy of rejection letter Annexure
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5. We have heard the Ld. Counsel for the parties and have carefully gone through the record on the file. Ld.counsel for the parties stated at bar that they do not want to file written arguments and the contents of the complaint as well as written version alongwith exhibited documents be read as part of written arguments.
Findings
6. From the appreciation of the facts and circumstances of the case, there is no dispute that the complainant obtained a Mediclaim Health Insurance Policy bearing No. 73091854 for the period 19.10.2024 to 28.10.2025 for a sum insured of Rs.25,00,000/- after paying premium of Rs.34,229/- which covered the complainant, his wife and minor son Master Mehtab Singh Bhangu. It is also not disputed that during the currency of the policy, the minor son of the complainant suffered from high-grade fever, vomiting, loose stools, poor oral intake and dehydration and was admitted at Apollo Hospitals Amritsar from 04.06.2025 to 06.06.2025, where he was diagnosed with AGE with severe dehydration. Medical expenses amounting to Rs. 31,148/- were incurred. However when the complainant submitted a claim the same was repudiated by the
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opposite party on the ground that hospitalization could have been managed on OPD basis and fell under exclusion relating to investigation/evaluation. Ld.counsel for the complainant has vehemently contended that the aforesaid act of the opposite party in repudiating the genuine claim of the complainant especially when no terms and conditions were supplied by the opposite party to the complainant amounts to deficiency in service and unfair trade practice. On the other hand the only plea taken by the opposite party is that policy terms and conditions were supplied through email and SMS and the claim was rejected strictly as per policy exclusions. Hospitalization was not medically necessary and could be managed on OPD basis and there is no deficiency in service.
7. This Commission has given thoughtful consideration to the facts of the present case and before going to the merits of the case perusal of the file shows that the opposite party alongwith written version has not filed affidavit to support the written version, as such no evidentiary value can be attached to the written version. Reliance in this connection has been placed upon Tarlok Singh Vs. Punjab State Electricity Board & Others 2004(1) CLT 127 of the Hon'ble Punjab State Commission, Chandigarh wherein it has been held that allegation mentioned in the complaint not stated in the affidavit and then those not verified to the
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knowledge of the complainant- Verification held not proper and affidavit cannot be considered to be supporting the complaint. Not only this the contention of the complainant is that no policy terms and conditions were ever supplied by the opposite party. In this regard the only plea taken by the opposite party is that terms and conditions were supplied through email and SMS. But we are not agreed with this plea of the opposite party mainly on the ground that it was for the opposite party to prove the factum that Insurance policy was delivered to the complainant with terms and conditions of the policy particularly when major chunk of the population in India is illiterate and every person is not familiar with the working of the electronic media. In support of this version this Commission has placed reliance upon The Oriental Insurance Co.Ltd. Vs. Satpal Singh & Others 2014(2) CLT 305 of the Hon'ble National Commission, New Delhi wherein in para 9 of this judgement held as under:-
"We are of the considered view that , onus of proof lies upon OP Nos.1 to 3 to prove that policy, alongwith terms and conditions, was supplied to the complainant. Ops had not produced any cogent evidence in this regard. The counsel for the petitioner drew our attention to the relevant portion of the cover note, which reads as:-
The insurance under this policy is subject to conditions, clauses, warranties, exclusions, IMTs and OIC endorsements, mentioned herein above which are available on company's website:
www.orientalinsurance.org.in or on demand from the policy issuing office."
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Hon'ble National Commission further held that "it's a ridiculous attempt, made by the counsel for the OP, it seems every driver/insured is a computer savvy…!! It proves that OP 1 did not supply ythe terms and conditions, with cover note."
8. However for the sake of arguments when we go through the merits of the case, the medical record shows that the insured child was suffering from severe dehydration, vomiting and fever and was admitted on the advice of the treating doctor. The Opposite Party has not produced any independent expert medical evidence to prove that hospitalization was unnecessary. It is a settled principle that the treating doctor is the best judge of the patient's condition. Mere assumption that treatment could have been managed on OPD basis is not sufficient ground for repudiation. So the act of the opposite party in repudiating the genuine claim of the complainant amounts to deficiency in service and the opposite party is liable to make good the loss by paying the claim amount to the complainant.
9. In view of the above discussion we allow the complaint and the opposite party is directed to pay the claim amount of Rs. 31148/- to the complainant. However, there is no order as to costs and compensation. Compliance of this order be made within 45 days from the date of receipt of copy of this order ; failing which opposite party will be liable to pay
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interest @ 7% p.a. on the awarded amount from the date of filing of the complaint till its realization. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission.
Announced in Open Commission (Jagdishwar Kumar Chopra) President
Dated: 24.2.2026
(Mandeep Kaur)
Member
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Present : Sh. Munish Kohli, Adv.counsel for the complainant Sh.R.P. Singh Adv.counsel for opposite party Vide our separate detailed order of even date, instant complaint has been Allowed as per terms of the detailed order. File be consigned to the record room.
24.2.2026 (Jagdishwar Kumar Chopra )
President
(Mandeep Kaur)
Member
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