Delhi

East Delhi

CC/310/2021

MRS MENKA - Complainant(s)

Versus

STAR HEALTH & ALLIED INS. - 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 – 110 092

 

C.C. No. 310/2021 

 

	MENKA PLOT NO.83, VIHAR, KAKROLA, NEW DELHI – 110078	….Complainant
Versus
	STAR HEALTH AND ALLIED INSURANCE COMPANY LTD. 209-210, LAKSHMI DEEP BUILDING, DISTRICT CENTRE, LAXMI NAGAR, DELHI - 110092	……OP1
	CLIFTON SPRINGS HOSPITAL PLOT NO.03, NEW ROSHANPURA, OPP. BDO OFFICE, KAPASHERA ROAD, NAJAFGHAR, NEW DELHI - 110043	……OP2

 

 

Date of Institution: 13.08.2021

Judgment Reserved on: 22.03.2023

Judgment Passed on: 03.04.2023

               

QUORUM:

 

Sh. S.S. Malhotra (President)

Ms. Rashmi Bansal (Member)

Sh. Ravi Kumar (Member)

 

Order By: Shri S.S. Malhotra (President)

 

 

 

JUDGEMENT

 

By this Order the Commission would dispose off the claim of the complainant with respect to deficiency in not reimbursing the medical bill of the complainant. 

Brief facts as stated by the complainant in the complaint are that she had an online Health Policy from Health and Allied Insurance Company dated 25.02.2020 being policy number P/161111/01/2020/028260 from 25.02.2020 to 24.02.2021.  She remained admitted in OP2’s Hospital i.e. Clifton Springs Hospital, Plot No.03, New Roshanpura, Opp. BDO Office, Kapashera Road, Najafgarh, New Delhi from 10.12.2020 to 14.12.2020, where a bill of Rs.32,814/- was raised which she paid in three installments i.e. Rs.15,000/- on 10.12.2020, Rs.10,000/- on 12.12.2020 and Rs.7814/- on 14.12.2020, but when she filed the claim before the Insurance Company being Claim No.CIR/2021/161111/2162870 dated 17.01.2021, the same was rejected interalia on the ground that “it is observed from the submitted medical records that the insured patient’s vital signs are stable throughout the period of hospitalization and the investigation reports are within normal limits.  Our medical team is of the opinion that hospitalization is not warranted.”  She served a legal notice on 08.04.2021 and another letter dated 19.06.2021 but OP has not given any reply and as such she has filed the present complaint against the OP thereby claiming Rs.32,814/- towards the medical reimbursement along with litigation charges.      

OP was served and could not file its written statement within time and opportunity of the OP2 to file the written statement has been closed vide Order dated 12.04.2022.  OP1 thereafter had filed Written Statement but since the same was beyond the statutory period, the same cannot be read for the purpose of its defence.  The Complainant has filed her evidence.   

The Commission has heard the arguments and perused the record. 

Irrespective of the fact that the OP2 has not filed any Written Statement/Evidence within the statutory period and its version cannot be considered for the purpose of its defence but there are certain facts mentioned by the complainant herself in the discharge summary which are relevant.  If the documents are perused the very first document is dated 09.12.2020.  This admission of the Complainant is without any history of the patient i.e. the Complainant.  Thereafter there is no prescription meanwhile w.r.t. the treatment and there is only a discharge summary dated 14.12.2000.   Discharge summary mentions the history i.e. patient was admitted in the hospital and certain other facts are mentioned, but without explaining as to what ailments she had, which necessitated her admission in the hospital.  The investigation paper/ reports which have been filed on record i.e. complete Hemogram, complete KFT, Serology, Biochemistry and Urine Examination Test and in none of the test any abnormality has been shown meaning thereby all the parameters were correctly functioning and were within the range.  The repudiation letter has also been placed on record by the Complainant and it reads as under:

“it is observed from the submitted medical records that the insured patient’s vital signs are stable throughout the period of hospitalization and the investigation reports are within normal limits.  Our medical team is of the opinion that hospitalization is not warranted.” 

Above all, the Complainant claims to be resident of Kakrola and she has got herself admitted at Clifton Springs Hospital which is situated at Nazafgarh and no reason has been explained as to why a patient who was in so such emergency, if any, would be travelling so much distance for getting admitted in hospital which is situated at a distant place that too without any specific ailments. 

In nutshell neither the ailments is explained nor the reason as to what necessitated the complainant to be admitted in hospital.  Nothing is mentioned in admission paper or in the discharge summary.  What ailment she had is also missing and clinical test indicates that she was not suffering from any ailments which requires hospitalization.  Even in the complaint it has not been mentioned as to what ailment she had been suffering with which necessitated her to be admitted in hospital.   

Keeping in view these facts, the repudiation letter as filed by the complainant herself appears to be reasonably explanatory and therefore there appears to be no deficiency on the part of OP1 in rejecting the claim of the Complainant.  Complainant has not been able to prove any deficiency on the part of OP2.  Therefore, claim of the Complainant against OP2 is also dismissed. Complaint of the complainant is accordingly dismissed against both the OPs.     

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

File be consigned to Record Room

Announced on 03.04.2023