Delhi

New Delhi

CC/377/2013

Chittaranjan Mishra - Complainant(s)

Versus

M/S. National Insurance Company Ltd. - Opp.Party(s)

27 Nov 2015

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI),

 ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE, NEW DELHI-110001

Case No.C.C./377 /13                                  Dated:

In the matter of:

       MR. CHITTARANJAN MISHRA

       S/o Shri J. Mishra

       R/o B-401, Gardenia Square,

       Crossing Republic,

       Ghaziabad, U.P.

 

       Earliest at:

       B-196, Pocket-II, Kendriya Vihar-II

       Sector-82, Noida, U.P.                                                                                                                 ………..COMPLAINANT

VERSUS

1.    M/s National Insurance Company Limited

       (A Govt. of India undertaking)

       Bancassurance Branch

       50, Janpath,New Delhi-110001

       Represented through its

       Branch Manager

 

2.    Park Medi Claim,

       702, Vikrant Tower,

       Rejendra Place,

       New Delhi-8

 

3.    Rashmi Medical Centre

       Nursing Home: IInd Floor,

       Krishna Complex, Nithari Chowk,

       Sector-31, Noida, U.P.

       Represented through

       Dr. K.C. Sood

….... OPPOSITE PARTIES

 

ORDER

Member  :  RITU GARODIA

 

          The complaint pertains to repudiation of medi claim by OP Insurance Company.  The complainant was covered under Swasthya Bima Policy vide policy No. 354502/48/11/8500002268 and was valid upto 15/12/2012.  The complainant was suffering from Dengue. He was admitted in OP-3 NursingHome on 15/10/2012 and was discharged on 22/10/2012.  Bills are annexed with the complaint.  OP-3 were informed of hospitalization on 16/10/2012.  A claim was filed.  It was denied by letter dated 29/1/2013 which repudiated it on grounds of non availability of round the clock doctor, thereby, not fulfilling the definition of hospital. Complainant had also submitted a certificate of OP-3 Medical Centre as required by OP-1 & OP-2.

          OP-1 Insurance Company in its version has stated that claim is heavily barred by condition No. 2.1.1 of policy.  It has further referred to clause 2.1 condition of policy.  OP has admitted that complainant was admitted in OP-3 Nursing Home.  OP further states that verification was carried out by TPA, OP-2, which shows that centre does not have round the clock doctor/nurses on duty.  OP-1 repudiated the claim.

          Perusal of the record, reveals that policy illness and subsequent hospitalization is admitted by both parties.  The only issue is whether OP-3 nursing home falls within the execution clause 2.1 and 2.1.1 which are reproduced as below:

2.1     HOSPITAL/NURSING HOME means any institution in India established for indoor care and treatment of sickness and injuries and which

EITHER

1. Has been registered either as a Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified Medical Practitioner.
382.  
2. Should comply with minimum criteria as under:

1. It should have at least 15 inpatient beds
2. Fully equipped operation theatre of its own wherever surgical Operations are carried out.
3. Fully qualified Nursing Staff under its employment round the clock.
4. Fully qualified Doctor(s) should be in-charge round the clock.

2.1.1  The Term ‘Hospital/Nursing Home’ shall not include an establishment, which is a place of rest, a place for the aged, a place for drug-addicts or place or alcoholics, hotel or a similar place.  

          The complainant has filed a certificate annexed at page 44 by Dr. K.C. Sood the OP-3 medical Centre.

This is to certify that Rashmi Medical Centre has

 

1. 15Indoor beds for treatment of Indoor patient
2. Fully equipped operation theatre/labour room/ and labs facilities.
3. Round the clock Nursing Staff and Resident Medical Officers on duty.
4. It has fulfilled the Nursing Home location. Its treatment address has been duly intimated after Hon’ble Supreme Court judgment in May 2012. 

 

          OP-2 has not filed it reply in the present case.  OP-1 has made a mere statement in its version regarding OP-2 verification without any evidence supporting the same. There is nothing in the record to allow us to disbelieve the certificate issued by a reputed doctor regarding the presence of number of beds and associated facility.

          In our considered view, OP-1 is gently of deficiency is not resolving the legitimate claim of complainant and arbitrarily repudiating the claim on frivolous and imaginary grounds and   directed to pay:

1. Rs. 68,923 with 9% interest p.a. date of claim till repayment.

 

 

2. Rs.50,000/- as compensation for mental agony, harassment due to unjustified repudiation.
3. Rs.10,000/- as litigation expenses.

 

(C.K.CHATURVEDI)

President

 

 

 

(RITU  GARODIA)

Member