Brief facts of the complaint that the complainant is a consumer of the respondent reason being he had taken a Medi Claim Policy from the respondent i.e. The Oriental Insurance Co. Ltd. Vide policy No.272490/48/2016/178. The period of alleged policy w.e.f. 30.10.2015 to 29.10.2016 for a sum of Rs.6.00 lac. On 11.02.2016, the complainant was admitted in Asian Institute of Medical Sciences, Sector-21-A, Faridabad. Where he remained hospitalized from 11.02.2016 to 13.02.2016 and complainant was discharged from the said medical institute on 13.02.2016. The complainant has spent Rs.29030/-(Rupees Twenty Nine thousand and thirty only) on medical treatment as indoor patient and hospitalization. The complainant informed the respondent on the day of hospitalization but the opposite party has refused to encashment the alleged claim to the above said hospital, even having a cashless policy and even after discharge from the said hospital. As per direction of the opposite party, the complainant has sent all the original treatment as well as medical bills along with the re-imbursement claim forms to the opposite party. But the opposite party has not reimbursed the claim of the complainant and the opposite party denied to reimbursed the claim of the complainant by demanding the baseless documents repeatedly which have already been filed by the complainant to the respondent through the alleged Asian Institute of Medical Science and also furnished by him in the office of the respondent and the complainant has now any previous decease of any kind and no any treatment was going on prior to this hospitalization and this information has already been furnished along with all the relevant demanded documents to the respondents and as per the terms and conditions of the policy, in the case of hospitalization a period of 24 hours should be completed and the complainant had been hospitalized for three days in the alleged hospital, but the respondent has illegally refused to make the payment to the complainant even having a cashless policy. That an application moved by the complainant before the Permanent Lok Adalat, Nuh on the same cause of action but the same was dismissed as withdrawn on 12.01.2018 with a liberty to file the present before any competent forum or court. Hence, this complaint with prayer to direct the respondent pay amount of hospitalization as indoor patient of Rs.29030/- along with a sum of Rs.1,00,000/- on account harassment, mental pain agony suffered by the complainant due to failure on the part of performance of respondent and also liable to pay Rs.25,000/- for litigation charges.
2. After registration of complaint, notice was issued to the respondent. Respondent in his reply has submitted that as per investigation report, claim form was not found to be genuine and as several discrepancies were found:
1) The name of the patient was added in policy on 30.10.2015 only and no previous policy prior to 30.10.2015 was found. A record of treatment prior to 11.2.2016 was also not found.
2) Coronary Angiography done but no record and bill were found to confirm it.
3) ICU protocol was not maintained.
4) Patient got discharged without advice.
5) Bill book was now shown.
6) Investigation like ECG, ECHO and CAG were done, but no record and bill were found to confirm it.
3. On the basis of evidence and documents collected by the investigating authority, it is concluded that the hospitalization at all is not justified and fraudulent means are adopted and used to make the claim payable. The answering respondent within the ambit of terms and conditions of policy, has repudiated the claim as per clause 5-8, which is as under:-
“Disclosure of information norm the policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of misrepresentation, mis-discreption or non disclosure of any material facts. As such the claim does not fall within the preview of terms and conditions as such the TPA had repudiated the claim.
4. It is denied that a sum of Rs. 29030/- has been spent as indoor patient and hospitalization or all the relevant documents have been supplied. It is submitted that the applicant has not supplied the documents required for investigation such as certificate from attending consultant providing
(a) Cause of Hypoglycemia in this case.
(b) Any past history of diabetes, hypertension, CAD or etch
And all the policy copies confirming covering coverage of the patient under medic aim policy prior to 30.10.2015, records of treatment taken before hospitalization, signed letter addressed to medical superintendent of the hospital requesting him/her to allow verification of inpatient records by TPA, self-attested copy of your photo ID proof issued by any Government Authority and reason for delay in submission of claim documents after 7 days of discharge from hospital. It is submitted that the applicant is not entitled to file the present application before the Hon’ble Forum as he has already availed the opportunity to file the present application before the competent forum and the PLA (PUS) has asked him to produce evidence to prove his case but the applicant could not produce the evidence despite being granted ample opportunities as such the applicant is not entitled to file the present application. The matter in controversy can only be resolved by leading evidence as such the Hon’ble Forum has got no jurisdiction to entertain and decide the present application. In the end he prayed that the complaint of the complainant may kindly be dismissed with costs.
3. Learned counsel for the complainant closed the evidence after tendering affidavit Ex. CW1/A and documents Ex. C-1 to Ex. C-24.
4. Learned counsel for the respondent closed the evidence after tendering documents Ex. R-1 and Ex. R-2.
5. Arguments heard and file perused.
6. The main objections of the opposite party are Nos. 1 to 6 in para No. 2 of this order. The objections taken by the O.P. seems to have been taken without any serious or support of either facts or law. The objections of the O.P. are duly addressed mainly in Ex. C1 to Ex. C24. The exhibit C1 being the discharge summary is the crux of all documents. Besides, Ex. C6 and Ex. C7 Angiography and Angiogram of the coronary. The exhibits placed on the file by the complainant addressed all the objections of the O.P. The addition of the name of the complainant in the policy is as per rules and the O.P. has failed to bring forward any cogent evidence on the file in this regard.
On the contrary, the complainant has proved his case by oral as well as documentary evidence beyond reasonable doubt. It is pertinent to mention here that the complainant was compelled to file this complaint even after directions to the O.P. vide order dated 21.12.2018 for redressal of the grievance of the complainant within a month which were not complied with.
In view of the above discussions in the foregoing paras of this order, this complaint succeeds and we pass an award of Rs. 29,030/- with interest at the rate of 9% per annum with effect from 04.06.2019 (date of filing of complaint) till realization against the O.P. The O.P. is also directed to pay Rs. 10,000/- towards litigation and compensation to the complainant. The opposite party is directed to comply of this order within 30 days after receipt of this order.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced on: 19.11.2019 (Rajbir Singh Dahiya)
President
District Consumer Disputes
Redressal Forum, Nuh (Mewat).
(Urmil Beniwal)
Member
District Consumer Disputes
Redressal Forum, Nuh (Mewat).
