State Consumer Disputes Redressal Commission
National Insurance Company Ltd vs Mrs Liya Ward on 26 March, 2026
M.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION
PLOT NO. 76, ARERA HILLS, BHOPAL (M.P.)
APPEAL NO. 1545/2023
National Insurance Company Ltd.
Through Divisional Office
Sanatan Dharma Mandir Road
Lashkar
Gwalior (M.P.) ... Appellant
VERSUS.
Smt. Lia Ward (Now Deceased)
Through Legal Heirs :-
1. Arthur Ward
S/o Late Bernard Ward
R/o - 18, Retired Colony, Ratlam
District Ratlam (M.P.) - 457 001
2. Carl Louis Ward
S/o Late Bernard Ward
R/o - 18, Retired Colony, Ratlam
District Ratlam (M.P.) - 457 001 ... Respondents
BEFORE;
HON'BLE JUSTICE SUNITA YADAV, PRESIDENT
HON'BLE DR. MONIKA MALIK, MEMBER
COUNSEL FOR THE PARTIES:
SHRI SANJEEV JAISWAL, LEARNED COUNSEL FOR APPELLANT.
SHRI PANKAJ BAJAJ, LEARNED COUNSEL FOR RESPONDENTS.
ORDER
( 26.03.2026 ) The following order of the Bench was delivered by Hon'ble Member, Dr. Monika Malik.
: 2 :
This appeal by the appellant/opposite party No.1- National Insurance Company Ltd (hereinafter referred to as 'Insurance Company'), is directed against the order dated 19.7.2023, passed by the District Consumer Disputes Redressal Commission, Ratlam (for short 'District Commission'), in complaint case No. 258/2021, whereby the District Commission has allowed the complaint filed by complainant/respondent (hereinafter referred to as 'complainant') and has directed the Insurance Company to pay to the complainant the remaining payable amount of the insurance claim i.e. Rs.8,15,560/-, with interest @ 6% per annum from the date of filing the complaint. Rs.20,000/- for deficiency in service with cost Rs.3,000/- has also been awarded.
2. Briefly put, facts of the case are that the complainant has been continuously taking mediclaim policy from the Insurance Company since the year 2012 and in continuation she obtained a policy for the period from 25.10.2017 to 24.10.2018, for an amount of Rs.10 lakhs. The policy was continuously renewed by the complainant till 25.10.2020. The complainant fell ill in the year 2015 and on investigations, it was : 3 : found that she was suffering from breast cancer. However, the Insurance Company did not pay the amount of medical expenses and also not did extend the benefit of cash less facility in terms of the policy. The complainant filed a complaint against the Insurance Company and based on a Court order, the claim amount was paid to her. It is further submitted that from 21.10.2020 the complainant consulted various doctors and was under treatment in different hospitals and she spent Rs.11,31,373/- in her treatment, out of which the Insurance Company approved only Rs.96,968/- on 18.10.2021. Therefore, alleging deficiency in service against the opposite parties, the complainant approached the District Commission, seeking relief.
3. The opposite party No.1/Insurance Company resisted the complaint and in its reply before the District Commission admitted that an insurance policy of Rs.10 lakhs was issued to the complainant. It is further submitted that the claim/ documents were examined by the medical experts, thereafter her claim was decided. The complainant's claim was not covered under policy condition No. 6.13, therefore the claim was rejected, as the complainant was not hospitalized for 24 : 4 : hours. It is further submitted that part of the admissible amount from the treatment bills has already been paid to the complainant. It is therefore, submitted that there is no deficiency in service on part of the Insurance Company and prayer for dismissal of complaint was made.
4. Heard. Perused the record.
5. Learned counsel for the Insurance Company argued that the District Commission has erred in passing the impugned order, as the claim was not payable in accordance with condition No.6.13 of the policy terms and conditions. The treatment which was sought in the instant matter was a 'day care' treatment, no hospitalisation was required and therefore, the District Commission has committed error in awarding the claim on the basis of sum assured. He, therefore, prayed that the impugned order be set aside.
6. Learned counsel for the complainant supported the impugned order and argued that the complainant's claim is covered by policy condition No.2.3, according to which the time limit of 24 hours is not applicable in treatment of certain conditions, including chemotherapy. The Insurance Company was therefore, rightly held deficient in service by the District : 5 : Commission. He, therefore, prayed that the appeal be dismissed.
7. Main objection of the Insurance Company is that 'Neoadjuvant Chemotherapy' is a day care procedure, which does not require admission and the mentioned therapy is not listed in the day care procedure list of the National Insurance Company Ltd. Also the claim does not fall under pre/post hospitalisation of any main claim where Cytotoxic drug was given. The Insurance Company, therefore, repudiated the claim on the basis of condition No.6.13 of the policy terms and conditions vide repudiation letter dated 28.6.2021 (Page 175 in the record of the District Commission) approved payment of Rs.96,968/- only.
8. It is pertinent to give mention of condition No 2.3 of the policy terms and conditions, which is reproduced as under :-
"Expenses of Hospitalisation for minimum period of 24 hours are admissible. However, this time limit will not apply for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy (Kidney Stone removal), Tonsillectomy, D&C taken in the Hospital/Nursing Home and the insured is discharged on the same day; the treatment will be considered : 6 : to be taken under Hospitalisation Benefit"
9. From the aforesaid, it is apparently clear that the expenses of hospitalisation for minimum period of 24 hours time limit was not applicable in the complainant's matter. The District Commission has also rightly observed that the Insurance Company has considered certain claims of the complainant and has ignored others.
10. Therefore, in view of the aforesaid, the complainant's claim deserves to be allowed and the same has rightly been considered by the District Commission.
11. To conclude, the District Commission has not committed any error or illegality in holding the Insurance Company deficient in service and by allowing the complaint.
12. The impugned order is hereby upheld.
13. The appeal fails and is dismissed.
14. No order as to costs.
(JUSTICE SUNITA YADAV) (DR. MONIKA MALIK)
PRESIDENT MEMBER
Mercy