CONSUMER DISPUTES REDRESSAL COMMISSION-VII

DISTRICT: SOUTH-WEST

GOVERNMENT OF NCT OF DELHI

FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN

CASE NO.CC/305/19

          Date of Institution:-    13.08.2019

          Order Reserved on:- 06.02.2024

                    Date of Decision:-      24.05.2024

IN THE MATTER OF:

Naresh Kumar

R/o 29 AN Block, Gopal Nagar,

Najafgarh, New Delhi - 110043

.….. Complainant

VERSUS

ICICI Lombard General Insurance Company

B-1, Plot No.4-2,

3^rd Floor,Agarwal Plaza Block,

Janakpuri, New Delhi - 110058

.…..Opposite Party

Suresh Kumar Gupta, President

1. The complainant has filed the complaint under section 12 of Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations thatOmbudsman has not given attention to the main facts of the case. The claim is related to the main claim. The earlier claims, which were not related to the main claims, were passed. The policy clearly shows that expenditure on themedicines consumed 30 days before the admission and 60 days after the discharge from the hospitalwill be reimbursed along with fees of the doctor. There is no word “main claim” in the insurance policy. The OP has deliberately transferred the amount of Rs.5000/- qua claim by NEFT in Axis Bank where he has already closed the account. He has demanded the papers from the Ombudsman from the rejection of the claim but papers were not supplied. The claim of Rs.56373/- + Rs.5000/- was rejected against the terms of the policy. Hence, this complaint.

2. The OP has filed the WS with the averments that complainant has taken health insurance policy which covers his wife and son. The policy was valid from 14.06.2017-13.06.2018. Sh. Sachin Kumar, Son of the complainant, was admitted for renal calculus at Orthoplus Hospital on 20.03.2018 and discharged on 25.03.2018. The cashless claim of Rs.18306/- was settled along with claim of Rs.5000/- for daily hospital allowances. The said amount of Rs.5000/- was transferred by NEFT on 18.04.2018. The complainant has approached the OP for post-settlement of cashless claim of Rs.56,373/- for reimbursement. The scrutiny of pre and post hospitalization documents shows that the claim was not related to the main hospitalization of the complainant. The insured was not admitted. He was taking OPD treatment and visited Anand Hospital for general consultation towards fever and loose motion. On 05.06.2018, SH. B. S. Singhal, treating doctor stated that he has given OPD treatment for malaria and fever which is not related to kidney stone treatment taken in Orthoplus Hospital. The statements dated 19.06.2018 and 22.06.2018 of Dr. B. S. Singhal annexed with the complaint are after thought as Doctor has changed his version to help the complainant. The OP vide letter dated 19.06.2018 has repudiated the claim as same is not related to the main diagnosis. There is no deficiency of service on the part of OP.

3. The complainant has filed the replicationwherein he has denied the averments of written statement and reiterated the stand taken in the complaint.
4. The parties were directed to lead the evidence.

5. The complainant has filed his own affidavit in evidence and corroborated the version of complaint and placed reliance on the documents Ex.CW1/1 – 7.

6. The OP has filed the affidavit of Sh.KrashanuPundir, in evidence and corroborated the version of written statement and placed reliance on the documents RW1/1-1/7.

7. We have heard the complainant and Ld. Counsel for the OP and perused the entire material on record.

8. The issuance of policy Annexure-R1/Ex.CW1/2 is not in dispute. The admission of the son of the complainant at Orthoplus Hospital for treatment of renal calculus thereafter settlement of claim of Rs.18306/- is not in dispute.

9. The question is whether the treatment of the insured from Anand Hospital was related to the main disease i.e. Renal Calculus.

10. The OP has filed the medical treatment papers of Anand Hospital along with receipts and medicine bills Ex.R4. Annexure-R7 shown as Ex.RW5 in the affidavit by the OP is OPD slip issued by Dr. B. S. Singhal of Anand Hospital which shows that insured was diagnosed with malaria as well as loose motion. The OPD slip reflects that insured has taken treatment of renal calculus from hospital. This document shows that insured was given treatment for fever due to malaria as well as for loose motions and not for his main disease renal calculus.The reflection of the tests like LFT and KFT does not in any way show that treating doctor has given treatment for renal calculus. The claim of Rs.56373/- Annexure-R3 was lodged which was rejected vide letter dated 19.06.2018 Annecure-R5.

11. The complainant has lodged the complaint with Ombudsman. The statement dated 05.06.2018 of Dr. B. S. Singhalshows that treatment was for malaria and fever. His subsequent certificates  dated 19.06.2018 and 22.06.2019 that treatment was for renal calculus does not inspire confidence as complainant has failed to give an explanation why the treating doctor has initially given the statement that treatment was for fever/malaria and loose motions. The subsequent change of statement is nothing but a method to help the complainant.

12. There is nothing on the record that the treatment from Anand hospital is related to renal calculus that is the main disease of the insured so the claim was rightly rejected by the OP. There is no deficiency of service on the part of OP in rejecting the claim.

13. In view of above discussion, the complainant has failed to substantiate the allegations as set out in the complaint and accordingly the complaint is dismissed.

• A copy of this order is to be sent to all the parties as per rule.
• File be consigned to record room.
• Announced in the open court on 24.05.2024.