DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST,
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 157/2016
D.No._________________________ Dated: _________________
IN THE MATTER OF:
Smt. REKHA GUPTA W/o SH. VIJAY GUPTA,
R/o C-4/254, C-BLOCK,
SULTAN PURI, DELHI-110086. … COMPLAINANT
Versus
1. HDFC ERGO GENE. INS. CO. LTD.,
PLOT No. C-9, 3RD FLOOR, PEARL HEIGHTS-II,
NETAJI SUBHASH PLACE, NEW DELHI-110034.
2. JAIPUR GOLDEN HOSPITAL,
2, INSTITUTIONAL AREA, SECTOR-3,
ROHINI, DELHI-110085. … OPPOSITE PARTY(IES)
CORAM :SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 11.01.2016
Date of decision: 26.06.2018
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against the OPunder Section 12 of the Consumer Protection Act, 1986 therebyalleging thatthe complainant and his family members took a Mediclaim Policy bearing policy no. 2952200838760801000 for the
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period from 08.09.2015 to 07.09.2017 and paid requisite premium of Rs.29,370/- by means of cheque to OP-1. On 31.12.2015, the complainant was suffering from fever and felt uneasiness and the husband of the complainant got the complainant to OP-2 and OP-2 immediately admitted and started treatmentand was discharged on 06.01.2016 after a period of 6 days. After admission in the hospital, the complainant through OP-2 applied for cashless treatment but the complainant was shocked to know that OP-1 has declined the request of the cashless facility provided in the policy issued by OP-1 and OP-2 raised a bill amountingto Rs.1,18,471/- which was duly paid by the complainant despite having the cashless treatment facility provided by OP-1. The complainant further alleged that the OP-1 has willfully rejected the genuine claim of the complainant without having rhyme and reason and due to that the complainant has suffered irreparable losses and paid the charges despite having the cashless treatment facility in the policy and hence there is clear deficiency on the part of OP-1.
2. On these allegations the complainant has filed the present complaint praying for direction to the OP-1 to pay an amount of Rs.1,18,471/- as hospitalization as well as other medical expenses. The complainant has also sought compensation of Rs.1,50,000/- for deficiency in service, mental agony and pain and financial loss,
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causing harassment mental and physical torture and huge financial loss to the complainant etc. The complainant has also sought Rs.20,000/- towards litigation cost.
3. OP-1 & OP-2 have been contesting the complaint and have filed their separate written statement. In its written statement, OP-1 submitted that the complaint is not maintainable andis liable to be dismissed asthere is no deficiencyin service on the part of OP-1. OP-1 further submitted that the complaint is pre-mature vis-à-vis OP-1 as no claim has been lodged by the complainant after discharge from the hospital. OP-1 further submitted that a Health Suraksha (Silver Plan) bearing no. 2952200838760801000 valid from 08.09.2015 to 07.09.2017 was issued in the name of Vijay Gupta, Rekha Gupta, Vishal Gupta & Vicky Gupta for a sum of Rs.5 lakhs and the liability of the company, if any, is subject to terms & conditions of the policy and a pre-authorization letter was received from the complainant through Jaipur Golden Hospital on 02.01.2016. However, a query was raised to supply the investigations report in support of diagnosis (Pneumonia) X-Ray chest indoor case papers, address proof of the proposer etc. in order to rule out the possibility of any exclusions and thereafter, on the basis of the documents submitted discrepancy was noted in the ailment history and co-morbidities and thus the cashless facility
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was denied vide letter dated 05.01.2016. OP-1 further submitted that it was advised to lodge a re-imbursement claim after treatment and discharge from the hospital where the claim would be processed on merit but no such claim was lodged by the complainant with OP and instead of lodging claim the complainant filed the claim.
4. OP-2 in its written statement submitted that the complaint is not maintainable, false, incorrect and baseless and is liable to be dismissed as against OP-2.
5. The complainant filed rejoinder and denied the submissions of the OPs and further submitted that the OPs have taken a misleading plea.
6. In order to prove her case the complainant filed her affidavit in evidence and also filed written arguments. The complainant also placed on record copies of Sarv Suraksha Policy-Personal Accident, Health Suraksha Policy-Silver Plan, copy of health card issued by OP-1 to the complainant, copy of attendant pass issued by OP-2, copy of patient bill (summary) issued by OP-2, copy of advance receipt issued by OP-2 and copy of discharge summary issued by OP-2.
7. On the other hand, Sh. Pankaj Kumar,Manager Legal ofOP-1 filed his affidavit in evidence and Sh. Suresh Kumar Kangra, Authorized
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Representative of OP-2 filed his affidavit in evidence. OP-1 & OP-2 have also filed written arguments.
8. This forum has considered the case of the complainant as well as OP-1 & OP-2 in the light of evidence and documents placed on record by the complainant. The documents and evidence of the parties shows that the complainant was admitted in the Jaipur Golden Hospital on 31.12.2015 and was discharged from the hospital on 06.01.2016 for treatment of Pneumonia right with acute lower respiratory tract infection in body which facts are not disputed.
9. As already discussed, the OP-1 has not disputed the fact that the complainant has taken a Mediclaim Policy. As per the policy, the sum insured was Rs.5,00,000/-. This Forum has considered the case of the parties in the light of the facts and evidence. The complainant has not filed a claim before OP-1 for re-imbursement of medical expenses after discharge from the hospital. Accordingly, it seems that the complaint is premature and the complainant ought to have filed a claim before OP-1 for re-imbursement of medical expenses. It further seems that the complainant has filed the present complaint before her claim was repudiated or rejected by OP-1. We are further of opinion that the complainant ought to have file the claim before OP-1 and only after repudiation of the claim by
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OP-1, the complaint could have been filed. Thus, the complainant is directed to file the claim before OP-1 for re-imbursement of medical and other expenses on the treatment of illness of the complainant and OP-1 is directed to decide the claim of the complainant within 3 months of the date of the filing of the claim by the complainant. In view of the above, the present case is dismissed. However, in case of repudiation/rejection of claim by OP-1, the complainant can approach the Forum again for redressal of her grievances.
10. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.
Announced on this 26thday of June, 2018.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
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