| Final Order / Judgement | ORDER Dated: Mohd. Anwar Alam, President - The complainant filed this complaint on 23-4-2009 and allegedthat patient Sh. Dinesh Chander was insured by the OP vide policy bearing no. 351600/46/08/8500000070 issued by the OP and a card bearing no. 60122/1070812786was also issued by the OP against the policy valid from 29-06-2008 till the renewal premium paid on time.. He further alleged that on 08-12-2008 Sh. Dinesh Chander got admitted under his care as he fell down from stairs leading to acuter lumbago (Prolapse intervertebral disc-PID) and MRI was done which showed L4-5PID. He also alleged that Pre-authorization was sent to OP on the same day for estimated expenses of Rs. 90,000/- and an approval of Rs. 25,000/- was received by the complainant. On confirmation of the MRI and after considering the seriousness of the patient , a surgery was planned for which he again sent revised estimate of Rs. 1,05,000/- and authorization letter dated 15-12-2008 annexed as Annexure C-3 and C4. The surgery was done and a total bill at the time of discharge was raised for Rs. 1,27,539/- on 17.12.2008 and complainant received authorization of Rs 60,000/-from the OP.Despite so many reminders and legal notice no response was filed by the OP hence he prayed that OP be directed to pay Rs. 1,27,539/- along with interest @ 18% p.a. , Rs. 100000/- as compensation for mental agony and harassment and Rs 10,000/- as cost of litigation.
- In reply, Insurance Company (OP2) stated that complainant is not a “consumer” and has never availed the services of OP2 and further stated that M/s FADEL MOGUL GOETZE (INDIA) Ltd has obtained medical policy from OP2 covering its employees and the employees were covered as per the status of employment and were divided into four categories. The IVth category employees were covered for Rs. 60,000/- for minor disease andRs. 2,00,000/- for major disease. Sh. Dinesh Chander a category IV employee was insured got admitted in Tirath Ram Shah Hospital on 8.12.2008 for which pre-authorisation sent by hospital to TPA who granted Rs 25,000/- on 8.12.2008 and later on enhanced the amount to Rs.80,000/- but as the disease was not covered under the nine major disease as specified in the policy therefore the above amount was reduced to Rs. 60,000/- accordingly. The complainant has no locus standi to file the complaint. Hence it was prayed that the complaint be dismissed with cost.
- In support of complaint complainant filed his own affidavit along with documents annexed as Annexure C-1 to Annexure C7. In support of reply OP1 filed affidavit of Mr.Rati Kant Kachroo and OP2 filed affidavit of Sh. A.S.N. Murthy , Divisional Manager. Both the parties filed their written arguments.
- We have heard the arguments and considered the evidence led by the parties and their written and oral arguments. In this case points to be considered are as under:-
(a) Whether complainant is a consumer? (b) Whether there is any deficiency in service on the part of the OP ? ( c) Relief? - Insurance policy EX. R2W1/1 of OP2 proves that M/s FADEL MOGUL GOETZE (INDIA) has taken group medicalim policy covering 17792 persons for category I , II , III and IV.. As it is evident from the complaint itself that the complainant was a treating doctor of patient Sh. Dinesh Chander. In fact, the patient Sh. Dinesh Chander was an employee of Category IV and covered under the above mediclaim policy of insuredM/s Fadel Mogul Goetze India Ltd. This complaint is not filed by Dinesh Chander northrough his authorized person. There is nothing on the record to prove that complainant is an authorized person for Sh. Dinesh Chandra. Hence in our considered opinion complainant is not consumer of the OP. As complainant is not a consumer under the Consumer Protection Act in this complaint case , therefore, this complaint is not maintainable.
- As complainant is not a consumer and the present complaint is not maintainable ,therefore, there is no need to decide remaining points of consideration in this case and the case is dismissed accordingly. Both the parties will bear their own cost and file be consigned to record room.
Announced on this …………….. | |
