Delhi

East Delhi

CC/1115/2014

MOHD.YASEEN - Complainant(s)

Versus

MAX BUPA HEALTH INS - Opp.Party(s)

14 Apr 2017

ORDER

           DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.    1115/2014

                                                                                                   Date of Institution              03/12/2014

                                                                                                   Order reserved on               14/04/2017        

                                                                                                   Date of Order                       17/04/2017                                                                                     

 

In matter of

Mr Mohd Yaseen, adult 

IX/4916 B, Gali no. 2   

Old Seelampur, Delhi 110031…..…….…………………...…………….Complainant

                                                                   

                                                                       Vs

The Manager,

Max Bupa Health Insurance Co. Ltd. 

B1/1,2 Mohan Cooperative Industrial Area  

Mathura Road, New Delhi 110044………. ……………….…………..Opponent

 

Quorum                              Sh Sukhdev  Singh       President

                                             Dr P N Tiwari                Member

                                             Mrs Harpreet Kaur      Member                                                                                             

 

Order by Dr P N Tiwari  Member  

Brief Facts of the case                                                                                                   

This complainant has been filed u/s 12 of C P Act, 1986 against OP for alleged deficiency in their services for rejecting accidental claim under Individual mediclaim policy.   

Complainant sustained accidental injury in his right upper shaft of humorous bone due to fall from his motor bike, so was admitted at Pentamed Hospital, Delhi on 24/11/2013 and was discharged on 26/11/2013. The discharge summary had been as marked Ex CW1/1.

The complainant had mediclaim policy from OP vide policy no. 30160217201301 valid from 29/12/2013 28/12/2014 for sum assured Rs. 2 lacs as annexed here Ex CW1/2 and CW1/2A. So complainant submitted his hospital bill sum of Rs 1,23,145/-with all medicine bills, Xray reports and treatment papers with claim form to OP vide Ex CW1/3.

 

 

The OP rejected the claim under clause 5e stating that “Due to mis representation of material facts about mode of injury” marked as Ex CW1/4.

The complainant thereafter also submitted a letter from treating doctor dated 18/01/2014 where doctor stated that “Patient had fallen from his bike due to slippery surface and sustained fracture in his right shoulder region” and his letter for considering his claim annexed here as Ex CW1/5, CW1/6 and CW1/6A.

Aggrieved by the rejection of his claim, filed this complaint claimed a sum of Rs 123145/- with compensation Rs 2Lacs for harassment and mental agony.

Notice was served and OP did not put their appearance despite of giving opportunities, so case preceded Ex Parte against OP. Complainant submitted his Ex Parte evidence on affidavit and stated on oath that his claim was genuine and all the required claim documents were submitted to OP. He also stated that his claim rejection was unjustified.

Arguments were heard and order was reserved.

After scrutinizing all the facts and evidences on record, it is to be seen whether complainant was entitled for claim benefit under policy terms and conditions after considering the following points as under –

1-Whether accident claimed was genuine by complainant,

2- Whether policy conditions were fulfilled by both the parties,

 

1-Whether accident benefits claimed were genuine by complainant

As per the facts of the complaint and evidences on record, it was seen that complainant met an accident on road side due to slipping from bike and sustained fracture injury in his right shoulder bone (upper shaft of humerus bone) and there were no other injury over his body. We have also seen the findings of discharge summery as “Slipped on floor” vide CW1/1 which is not complete and only one page was on record as duplicate copy and a letter from treating doctor stating that injury sustained due to “fall on slippery surface”.

OP in their rejection letter stated that both the facts were different as floor and surface in the treatment and doctor’s letter and both the facts were not same and had different meaning, so rejection under clause 5E was justified. We have also seen his claim policy details. The complainant has filed policy vide Ex CW1/2 and CW1/2A as in downloaded policy copy bearing policy no. 30160217201301 and his claim was rejected under policy no. 30160217201200 vide his claim form Ex CW1/3 which was incomplete and not readable. Also annexed policy document and claimed under policy was not matching. Rejection letter showed reason of claim rejection as “mis representation of correct facts/incident for mode of injury”.

Slippery surface means any place or spot with wet or greasy material over road leading to slipping of his bike and accidently sustained injury, but in such case, a person sustains multiple injuries over his body especially on the side of fall. Slipped on Floor means sustaining injury over floor/in house/hall or office floor and will get injury accidently over that part of body may be ankle, leg, wrist or shoulder joint. So both the facts have different meaning.       

Also complainant had not submitted zerox of hospital bill, complete discharge summary, lab reports, X Ray reports before operation and after operation with chemist bills. Thus based on the above facts, claim was not filed with correct facts and evidence. Annexed documents were also not correlating with his complaint.  

2- Whether policy conditions were fulfilled by both the parties

It was seen that the complainant took policy from OP but has not filed correct policy documents for claim. Annexed policy and rejection under the stated policy no. were different. Hence, complainant had not submitted correct and required documents to OP.    

So, rejection of claim by OP was justified. Hence, we are of the opinion that complainant had not able to prove the deficiency of OP in their services. Thus, we are of the opinion that this complaint has no merit and same deserves to be dismissed, so dismissed without any order to cost.  

Copy of this order be sent to the parties as per the Act and file be consigned to Record Room.

 

(Dr) P N Tiwari   Member                                                                   Mrs Harpreet Kaur  Member                                   

                                       

                                           Shri  Sukhdev Singh - President