JUDGMENT

1. The present complaint has been filed by the complainant before this commission for  the following reliefs-

1. The Op be directed to pay medical expenses Rs.113362 with 18% interest.
2. The Op be directed to pay compensation Rs.350000 for mental agony.
3. The Op be directed to pay litigation expenses Rs.20000/.

2. The Complainant has stated that the complainant obtained the medi claim policy for health under Optima Insurance Plan during the period from 15.9.2020 to 16.9.2021 and thereafter from 16.9.2022 to 15.9.2023. whereby the complainant and his wife Seema Sharma, daughters Nikky Sharma and Bindiya Sharma and son Bharat Sharka were insured.  Complainant’s daughter Km. Bindiya Sharma came under the grip of high fever, abdomen  pain and bottoming and she visited the  Max “Fort Multi Specialty Hospital, Ramghat Road, Aligarh on 12.11.2022 who was admitted in hospital for proper treatment. Blood tests were conducted and she was found under the grip of dengue reactive with Thrombocytopenia and was given treatment for the same. She remained in hospital up to 16.11.2022.   
3. Ops did not submit WS despite of sufficient service and case was processed ex parte.    
4. Complainant has filed his affidavit and papers in support of his pleadings.
5. We have perused the material available on record and heard the complainant’s counsel.
6. Complainant has claimed medical expenses and other expenses incurred in treatment in the hospital. As per unrebutted pleadings, the amount of expenses incurred by the complainant becomes final. So far as question of repudiation of the claim is concerned, Op has rejected the claim on the ground of exclusion no.11 providing exclusion of the hospital by the insurer and disclosure in its website/notified to the policy holder. The complainant entered into contact of insurance with the OP on 16.9.2022 and on that day the hospital where the treatment was given to the treatment was included in the list of hospital as is evident from the website of the OP. The OP cannot modify the contract without participation of the complainant. Complainant was never informed about the exclusion of the hospital and disclosure on website cannot be treated as notice to the complainant and is mere general information which is not sufficient to modify the contract on the pretext of giving information on website. Thus the OP is bound by the contract to reimburse the complainant and cannot be escaped from the liability under the contract of insurance which was enforceable during period of treatment.  We are of the view that the complainant is entitled for Rs.113362 with pendente lite and future interest @9% per annum.             

7. We hereby direct the Ops to pay the amount Rs.113362 with pendente lite and future interest @9% per annum. OPs shall also pay to the complainant Rs.10000/for litigation expenses and Rs.10000 for mental agony.
8. Ops shall comply with the direction within 30 days failing which Ops shall be prosecuted for non-compliance in accordance with section 72 of the Act for awarding punishment against him.
9. A copy of this judgment be provided to all the parties as per rule as mandated by Consumer Protection Act, 2019. The judgment be uploaded forthwith on the website of the commission for the perusal of the parties.
10. File be consigned to record room along with a copy of this judgment.