Delhi

East Delhi

CC/666/2014

KANTA PRASAD - Complainant(s)

Versus

NIC - Opp.Party(s)

03 Apr 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110092

 

C.C. NO. 666/2014

 

	Kanta Prasad Prajapati, Father of Minor Child Dilip Kumar, R/o H.No.-93 Gali No.-4, Near Geeta Bal Bharti School, Shankar Nagar, Krishna Nagar, Delhi-110051	….Complainant
Versus
1.         2.	National Insurance Company Ltd.. & Otrs, Through Its Director/A.R./Manager Issuing Branch Office At:- 1566/3 Charch Road, Kashmiri Gate, Delhi-110006.   M/S Vipul Med Corp Tpa Pvt. Ltd. Tpa Of National Insurance Company Ltd. Branch Office At:- 515 Udyog Vihar Phase-5, Gurgaon, Haryana, India Through Its Director/A.R./Manager	…OP1                                                                                   …OP2

 

Date of Institution: 23.07.2014

Order Reserved on: 22.02.2023

 Order Passed on: 03.04.2023

               

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms.Rashmi Bansal(Member)

 

 

Order by : Sh. S.S. Malhotra (President)

 

 

JUDGMENT

 

1. By this judgment the Commission shall dispose off the claim of the complainant with respect to deficiency in service in not reimbursing the amount of the medical treatment against the policy in favour of the complainant as issued by the OP1.
2. Brief facts as stated by the complainant in the complaint are that he had a mediclaim policy from the OP1 and he paid the Rs. 827/- having medical coverage of Rs. 50,000/- which policy included the complainant himself, his wife, his son & his daughter.
3. On 28.05.2014 son of the complainant Sh. Dilip Kumar was hospitalized and was admitted in Goyal Hospital & Urology Center with severe stomach pain and remained admitted there upto 01.06.2014 on which date he was discharged and complainant spent Rs. 50,000/- in the treatment. The complainant then approached OP for reimbursement of amount of Rs. 50,000/- but it was declined vide repudiation claim letter which is Annexure-B and thereafter various letters were written but OP has not reimbursed the claim and he has filed the present case seeking direction to the OP1 to pay Rs. 50,000/- towards reimbursement of expenses, Rs. 40000/- towards compensation and Rs. 50,000/- towards litigation expenses.
4. The OPs were served and OP1 filed its reply interalia stating that the present complaint is liable to be dismissed as complainant has suppressed material facts and in fact there was a gap of 37 days in renewal of the previous policy on 27.12.2013 and as such because medical policy was discontinued w.r.t. 29.11.2013 and since there was break in the policy, so the fresh medical policy of the complaint has been treated as a fresh policy being effective 27.12.2013 and since the policy was a fresh one, terms & conditions of the policy have to be read in conformity with the existing terms & conditions and as such the cashless request was not processed under clause 4.1 of BOI National Swasthya Bima Policy & the same was treated an ailment in first year of the policy and the claim falls within the exclusion clause 4.1 and therefore, the amount of the client was not reimbursed.  
5. Further it is submitted that the repudiation letter was issued on 31.05.2014 in which reason in not processing was mentioned and as such there is no cause of action in filing the complaint nor there is any deficiency on the part of OP & complaint of the complainant be dismissed. On merit facts of preliminary objections are reiterated and it is submitted that complaint of the complainant be dismissed.
6. Complainant has filed rejoinder thereby denying the contents of the written statement and reiterated the contents of the complaint. The complainant has filed his evidence & has exhibited only two documents i.e. (i) Policy as Ex. CW-1/1 (ii) Repudiation Letter/Claim as Ex. CW-1/2. OP has filed evidence of Sh. Ramesh Chand, Divisional Manager. The OP has also filed written arguments, complainant has filed written arguments on 22/02/2023.
7. The Commission has perused the record. In nutshell the complaint is that he had a family policy for Rs. 50000/- and his son Sh. Dilip Kumar was admitted in Goyal Hospital & Urology Center on 28.05.2014 and discharged on 01.06.2014 and spent Rs. 50000/- on the treatment which the OP has not reimbursed. The defence of the OP in nut-shell is that there was a policy of the complainant which was got renewed after 37 days of the expiry & the new policy was treated as a first year policy, as there was difference of 37 days in renewing the policy from the last year to the current year and in view of the exclusion clause 4.1 claim is not maintainable.
8. Irrespective of the fact that whether the policy was new or old or whether the OP was rightful in treating the policy as first year policy thereby invoking the clause 4.1 i.e. exclusion clause, the first contention which has to be appreciated is as to how much was the bill paid by the complainant to the hospital. In the entire complaint or in the evidence or even in the entire written arguments filed by the complainant on 22/02/2023 it has nowhere been clarified as to what amount the complainant had paid to the hospital and against which invoice number. There was no invoice attached to the complaint & in absence of any bill placed on record, it cannot be appreciated as to how much amount the complainant has spent on the treatment of his son in the hospital which is sought to be reimbursed and since there is no bill no order can be passed for indemnification of any amount on the basis of policy. The complaint of the complainant is accordingly dismissed.

Copy of the order be supplied/sent to both the parties free of cost as per rules.

File be consigned to Record Room.

Announced on 03.04.2023.