DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-WEST

GOVT. OF NCT OF DELHI

CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.

CC. No.1261/2008                                       

IN THE MATTER OF :

1. Sh. Sandeep Dhawan

S/o Sh. S.P. Dhawan.

2. Smt. Vandana Dhawan,

W/o Shri Sandeep Dhawan,

Both resident of:-

BFH-38, Shalimar Bagh West,

•                                                ….                               Complainant(s)

VERSUS

Hygeiacare Comprehensive Health Management Services Pvt. Ltd.,

Through its Director

Having their Corporate office at:

6, 2^nd Floor, Central Market,

West Punjabi Bagh,

New Delhi-110025                                                              ….                              Opp. Party

NIPUR CHANDNA, MEMBER

ORDER

The brief facts of the complaint are as under:-

1. Complainant is having a Mediclaim policy from the OP for himself and his wife since 2006.  The same was renewed from time to time.  Since the wife of complainant was seven months pregnant, the complainant got the mediclaim policy renewed by paying the premium of Rs.8585/- vide cheque dated 02.08.2008. On 25.08.2008 the wife of complainant was admitted in the hospital as there was some complications in her pregnancy.  The pre hospitalization form was filled and sent to the TPA of the OP for approval.  But no approval was received from the OP for six days.  Due to non receipt of approval, the father of complainant visited the office of OP and requested the officials of OP to do the needful. The officials of OP flatly refused to entertain the complaint and further added that the maximum limit of reimbursement is to the tune of Rs.15,000/- against maternity benefit and not Rs.50,000/-, as claimed by OP. Having no other option, complainant paid a sum of Rs.1,16,018/- to the hospital.  It is stated that OP is bound to pay a sum of Rs.50,000/- to him as assured by OP during the issuance of policy.  The complainant further states that the non-reimbursement of the claim of the complainant by the OP amounts the deficiency in service, hence this complaint.

2. Perusal of the records shows that the OP filed its written statement and after that despite several opportunities, none appeared on behalf of OP nor other pleadings were completed.  Hence, as per the order dated 20.01.2009 of our Predecessor Bench, the OP was proceeded exparte. 

3. We have heard the arguments advance at the bar on behalf of complainant. Perusal of the file shows that the complainant has placed on record copy of premium deposit receipt dated 11.08.2008 which clearly shows that the complainant had paid the premium to the OP. The complainant has failed to place on record the policy document which is vital document to substantiate his claim of Rs.50,000/- as alleged by him. Proposal form placed on record does not clarify the period of insurance as well as the sum assured by the OP Company. In such circumstances, we are of the considered view that the complainant has failed to substantiate his claim of Rs.50,000/- as alleged in the complaint.

4. In view of the above, we find no merit in the present complaint and same is hereby dismissed.

5. Copy of the order may be forwarded to the parties to the case free of cost as statutorily required. The orders be uploaded on www.confonet.nic.in. File be consigned to Record Room.

Announced in open Forum on_____________.

                                       (ARUN KUMAR ARYA)

                                                  PRESIDENT

(NIPUR CHANDNA)                                                             (R C MEENA)

  MEMBER                                                                                MEMBER