Delhi

North East

CC/251/2023

Sh. Yogendra Kumar Verma - Complainant(s)

Versus

Manipal Cigna, Health Insurance Company Ltd. - Opp.Party(s)

03 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 251/23

 

In the matter of:

 

	Sh. Yogendra Kumar Verma S/o Lt. Sh. Brahma Nand Verma, R/o 603/2 B/1 A, Main 60 ft. Road, Bazar Gali, Vishwas Nagar, Delhi-110032	Complainant
	Versus
	Manipal Cigna, Health Insurance Co. Ltd. Through its Principal Officer, Office at:- 1/7, 1st Floor, above SBI Bank Near Patel Nagar Metro Station, East Patel Nagar, New Delhi-110008	Opposite Party

 

 

CORAM:

Surinder Kumar Sharma, President

Adarsh Nain, Member

ORDER

Ms. Adarsh Nain, Member

1. The Complainant has filed the present complaint under Section 35 of the Consumer protection Act, 2019 the Opposite Party Manipal Cigna, Health Insurance Co. Ltd. As per the Complaint, the complainant purchased Master policy no. 10020000000/05/00, certificate no. 100100053440/04/00, Member ID no. 107740801 for himself from Opposite Party. The Complainant stated that he had intimated the Opposite Party that he had undergone liver cirrhosis treatment with Ayurvedic Medical Jhabrera, Haridwar w.e.f 30.05.23.  The Complainant stated that Chikitsa Kendra raised bills along with prescriptions for total sum of Rs. 47,779.25/- and a separate ultra sound of Rs. 1,000/- totalling to Rs. 48,779.25/-. The Complainant had submitted said bills along with prescription to Opposite Party by way of mediclaim prescribed proforma on 26.06.23. The grievance of the Complainant is that the Opposite Party has not considered the treatment of the Complainant and therefore, repudiated the said claim of the Complainant in terms of the policy clause D.1.2. It is alleged that the Opposite Party neglected to pay the mediclaim amount/dues of the Complainant to the tune of Rs. 48,779.25/- under the policy in spite of repeated requests and reminders. The Complainant has prayed for reimbursement of the claim amount as well as the compensation for mental harassment.
2. Arguments heard on admission. Perused the file.
3. The perusal of the material on record reveals that the Complainant was duly insured with the Opposite Party company and the claim of the Complainant was not considered by the Opposite Party and rejected.
4. The perusal of repudiation letter accompanying the Complainant shows that the Opposite Party has repudiated the Complainant claim on the ground that the OPD expenses are not covered under the policy.
5. We have perused the prescriptions and medicine bills filed by the Complainant and observed that the Complainant had taken treatment at Jan Kalyan Chikitsa Kendra on OPD basis.  The copy of the policy document accompanying the present complaint clearly shows that only In-patient hospitalization expenses including pre-hospitalization and post-hospitalization medical expenses are covered. During arguments on admission also, the counsel for the Complainant admits that the Complainant was not hospitalized for the treatment.
6. In view of above discussion, we are of the considered view that since, the Complainant has neither filed any document showing his hospitalization nor has been able to show that OPD expenses were covered under the policy, no case is made out against the Opposite Party showing deficiency in services towards the Complainant. We find the present complaint devoid of any merit to warrant its admission.
7. Thus, the present complaint is dismissed with no order as to costs.
8. Order announced on 03.10.23.

Copy of this order be given to the Complainant free of cost.

File be consigned to Record Room.

 

(Adarsh Nain)             Member

(Surinder Kumar Sharma) President