CONSUMER DISPUTES REDRESSAL COMMISSION – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110016
Case No.169/2016
SH. SURINDER KAMRA
R/O QU-85 A, PITAMPURA
NEW DELHI-110094 … ..COMPLAINANT
Vs.
- NATIONAL INSURANCE COMPANY
SAHYOG BUILDING 58, 302-304,
-
NEW DELHI-110019 …..RESPONDENT NO.1/OP
ALSO AT
- FOCUS HEALTH SERVICES (T.P.A) PVT. LTD.
AB- 16, COMMUNITY CENTRE,
SAFDARJUNG ENCLAVE,
NEW DELHI-110029 …..RESPONDENT NO.2/OP
Date of Institution-25/05/2016.
Date of Order-01/04/2022.
O R D E R
RASHMI BANSAL– Member
The present complaint is filed by the complainant against OP, namely, National Insurance Company, seeking relief for passing his claim of Rs. 39,883/- (Thirty Nine Thousand Eight Hundred Eighty three rupees) with interest at the rate of 18 % from the date of claim to the actual realisation of the amount.
The facts of the case are that the complainant had taken a medi-claim policy bearing number 354802/48/13 /8500002622 from OP1, having its office at Nehru Place, New Delhi, for the period 02.01.15 to 01.01.16, exhibited as exhibit CW1 / A (colly). OP2 is the third party agent of OP1. OP2 has been proceeded ex-parte vide order dated 11.07.2016. OP1 and complainant have tendered their evidence by way of affidavit as well as written submissions. Rejoinder by complainant and the written statement by OP1 is also on record. Oral arguments are heard and concluded.
Complainant states that on 29.01.2015, complainant was bitten by a dog and immediately rushed to the hospital in his locality. The date has been wrongly mentioned in the complaint and in the legal notice as 24.01.2015. Doctor gave necessary treatment and the complainant was referred to Safdarjung Hospital for taking injections for rabies. The complainant reached the hospital on 29.01.2015 and came to know that rabies injection was not available in Safdarjung hospital, therefore he purchased the prescribed injection from the chemist. The copy of the OPD card issued by Safdarjung Hospital along with the copy of the bill of the chemist bearing number 18936 dated 29.01.2015, amounting Rs. 18,692/-, exhibited as exhibit CW1/B (Colly).
Complainant was further prescribed some more medicines which were purchased from another chemist amounting to Rs. 290 vide Bill number A153469, dated 30.01.2015 exhibited as exhibit CW1/C.
The complainant has submitted a claim of Rs. 19,883/-, including payments towards injection of Rs. 18,692, medicine of Rs. 290, taxi fare of Rs. 500/- and conveyance of Rs. 400/- , through claim form dated 16.03.2015, exhibited as CW-1/E. The complainant alleges that his claim has not been reimbursed by OP1. The legal notice dated 11.04.2016 is exhibited as exhibit CW1/D, was also sent to OP1 and OP2 but no response has been received from them despite repeated reminders, both telephonically and personal visits to their respective offices.
OP1, in its reply, has admitted that Parivar Mediclaim policy was taken by complainant, subject to standard terms and condition of hospitalisation benefit policy, however, the period for insurance policy is disputed, and stated that insurance was valid for the period 02.07.2015 to 01.07.2016. Further, OP has stated that complainant was taken to Baba Saheb Ambedkar Hospital on 29.01.2015 with complaint of dog bite. This is further submitted by OP1 that after receipt of the claim from the complainant, OP1 deputed claim department of OP2 to assess the claim of the complainant. The claim department has repudiated the claim of complainant stating that the claim pertains to vaccine charges for dog bite and same is not covered under the scope of policy. The claim merits repudiation as per Exclusion clause 4.5 of the Parivar Mediclaim Policy.
Exclusion Clause 4.5 of the policy reads as follows:
“Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment by any description, plastic surgery other than as may be necessitated due to an accident as a part of any illness.”
Thereafter, OP1 also examined the claim of the complainant and reached the conclusion that the same is not covered under the policy and is barred under exclusion clause 4.5 of the policy. OP stated that there is no deficiency of service on the part of OP and complainant cannot be permitted to make an illegal gain out of an unfortunate event and that complainant is not entitled to any relief and is liable to be dismissed with heavy cost.
Heard and perused the factual matrix involved and pleadings on record.
Exhibit CW1/A (Colly) Medi-Claim policy bearing number 354802/48/13/8500002622 shows the policy tenure for the period 02.01.15 to 01.01.16. Therefore, at the time of dog bite to the complainant, the policy was in force.
Exhibit CW1/B (colly), which is the OPD card dated 29.01.2015 of Safdarjung Hospital, has diagnosed as dog bite and under the treatment column has written ARS (Anti Rabies Serum) given. The bill number 18936 dated 29.01.2015 (Ex CW1/B, colly) amounting Rs. 18,689/- mentions doctor’s name as Dr Babasaheb Ambedkar Hospital, while as per the complainant statement the injection has been prescribed by Safdarjung Hospital and therefore, the name of the Safdarjung Hospital should be reflected on the bill. The other bill number A153469 dated 30.01.2015, exhibit CW1/C, also reflects the name of the doctor as Babasaheb Ambedkar Hospital and not of the Safdarjung Hospital. The medicine mentioned in the bills are also not prescribed by the Safdarjung Hospital. The bills and prescription of the Safdarjung Hospital do not corroborate which creates doubt about the genuineness of the bill.
The claim form, exhibit no CW1/E, vide its clause 7 shows name and address of the attending medical practitioner as Dr Baba Saheb Hospital Rohini, clause 8 (a) shows name and address of the hospital nursing home clinic as mentioned above and Safdarjung Hospital. The date of admission is shown as 29.01.2015 and the date of discharge as 30.01.2015. This is observed from the pleadings on record that there has never been any admission of the complainant in the hospital nor the same has been mentioned at the OPD card of the Safdarjung Hospital. When there is no admission to the hospital, the question of discharge does not arise at all. Also, no discharge summary has been filed by complainant.
Clause 9 of CW1/E require details when claim is related with Domiciliary Hospitalization, then the date of commencement of treatment and date of completion of the treatment, which is mentioned by the complainant as 29.01.2015 and 26.02.2015 respectively and in column 9(c), for name and address of attending medical practitioner has been mentioned ‘N.A’. The pleadings and the annexures as presented by complainant very clearly establish that the complainant has been treated as outpatient and has never been hospitalized.
The claim filed by the complainant is not in accordance with the statements of the complainant and also not substantiated by the evidences. The complainant himself has filed the contradicting evidences, mentioning Safdarjung hospital at one place and mentioning other hospital in claim form. Even the bill receipts of the chemists bears the name of Baba Saheb Ambedkar Hospital.
Considering the above circumstances, and the pleadings on record, this commission is of the view that complainant has miserably failed to establish his case and has been contradicting himself throughout the pleadings. Complaint is hereby dismissed. There is no order as to costs. The copy of the order may be given to each party free of cost. File may be consigned to Record room.
(Dr. RAJENDER DHAR) (RASHMI BANSAL) (MONIKA A SRIVASTAVA)
MEMBER MEMBER PRESIDENT
