Delhi

New Delhi

CC/670/2010

Mukesh Sharma - Complainant(s)

Versus

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

01 Jul 2015

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI), ‘M’ BLOCK, 1^STFLOOR,

VIKAS BHAWAN, I.P.ESTATE,

NEW DELHI-110002.

 

Case No.CC/670/10                                                                                                                                                                                Dated:

In the matter of:

Sh. Mukesh Sharma,

B-11/133, Pharma Apartments,

88, I.P Extension, Delhi-110092

 

 

……..COMPLAINANT

       

VERSUS

National Insurance Co. Ltd,

Divisonal Office-XV,

Himalaya House, 1st Floor,

13, K.G Marg, New Delhi-110001

 

                                         ……. OPPOSITE PARTIES

 

 

ORDER (Oral)

Date of Arguments: 01.07.2015

President: C.K Chaturvedi

Present:    Counsel for the Complainant.

                None for the OP.

                Arguments heard.      

 

The Complaint is pertaining to arbitrary repudiation of claim of medical policy taken by complainant from OP.  Complainant took policy in 2003 for himself and his family and policy continue by last renewal of policy for period 16.11.08 to 15.11.09 for sum of Rs.1,75,000/- for himself and Rs.75,000/- for his wife. Complainant wife on 07.04.09, was taken to Centre for Joint Rejuvenation Hospital for medical checkup due to pain her in both Knees and she was advised Cyclotron Therapy for 21 days for 3 months. Complainant spent a sum of Rs.1,32,325/- towards treatment and thereafter presented claim for Rs.95,000/- being the sum insured under the policy through TPA.

OP repudiated the claim stating that expenses incurred during hospitalization are excluded under the scope of the policy. Hence, OP denied the claim. Thereafter, complainant filed complaint against the deficiency.

OP filed reply stating that Complainant was barred as per exclusion clause 4.13 of the terms and conditions as per policy which do not provide treatment for Naturopathy, unproven procedure/treatment, experimental or alternative medicine/treatment including acupuncture, acupressure, magneto-therapy etc. It stated that the procedure undergone for treatment by complainant, which is more or less similar to magnetic therapy, but OP has failed to produce in any evidence this regard. The burden to prove the same is only on OP.

We have considered the treatment record of complainant including certificate issued by Centre for Joint Rejuvenation stating that “she has been diagnosed with Osteo arthritis for both knees and advised for Cytotron Therapy which uses RFQMR technique for cartilage rejuvenation. Cytoton therapy is O.P.D treatment and doesn’t require hospital stay. Estimated cost for 21 days and 3 months follow up for both the knees will be Rs.1.30 lac.”

In absence of any specific evidence in support of case of OP, complainant case cannot be arbitrarily rejected on basis of allegations of OP or on basis similarity of procedure. Hence, OP is held guilty of deficiency in service and directed to refund sum of Rs.95,000/- to Complainant. We also award Rs.25,000/- for litigation expenses.

File be consigned to record room.

Copy of the order be sent to the parties free of cost.

 

        Pronounced in open Court on 01.07.2015.

 

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

 (Ritu Garodia)

MEMBER